Health, Dignity, and Development: What Will It Take?

First published by Earthscan in the UK and USA in 2005
Copyright 2005
by the United Nations Development Program
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The Millennium Project was commissioned by the UN Secretary-General and sponsored by the United Nations
Development Programme on behalf of the UN Development Group. The report is an independent publication that
reects the views of the members of the Task Force on Water and Sanitation, who contributed in their personal capacity. This publication does not necessarily reect the views of the United Nations, the United Nations Development
Programme, or their Member States.
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Foreword
The world has an unprecedented opportunity to improve the lives of billions

of people by adopting practical approaches to meeting the Millennium Development Goals. At the request of UN Secretary-General Ko Annan, the UN
Millennium Project has identied practical strategies to eradicate poverty by
scaling up investments in infrastructure and human capital while promoting
gender equality and environmental sustainability. These strategies are described
in the UN Millennium Projects report Investing in Development: A Practical
Plan to Achieve the Millennium Development Goals, which was coauthored by
the coordinators of the UN Millennium Project task forces.
The task forces have identied the interventions and policy measures
needed to achieve each of the Goals. In Health, Dignity, and Development:
What Will It Take? the UN Millennium Project Task Force on Water and Sanitation emphasizes that achieving the water and sanitation target and investing
in water infrastructure and management are crucial to the achievement of all
the Millennium Development Goalsa key point that is echoed in Investing
in Development.
Consider, for example, the sanitation crisis. Four in ten of our fellow
women, men, and children have no choice but to defecate in buckets, in plastic bags, in open elds, and alongside footpaths, streets, and railroad tracks,
not occasionally but every single day. This persistent yet largely unrecognized
humanitarian crisis must end if we are to reduce disease, hunger, and gender inequality; improve the lives of slum dwellers; and achieve environmental
sustainability. Conversely, progress toward these and other Millennium Development Goalsparticularly the reduction of poverty and gender inequality
is vital to achieving the water and sanitation target and to improving the use
of Earths water resources.
iv
Foreword
Health, Dignity, and Development has been prepared by a group of leading

experts who contributed in their personal capacity and volunteered their time
to this important task. I am very grateful for their thorough and skilled efforts,
and I am sure that the practical options for action in this report will make an
important contribution to achieving the Millennium Development Goals. I
strongly recommend it to anyone who is interested in how countries can make
the dream of safe drinking water and basic sanitation a reality for their poorest
citizens.
Jeffrey D. Sachs
New York
January 17, 2005
Contents
Foreword
iii
Task force members
x
Preface
xii
Acknowledgments
xv
Millennium Development Goals xviii
Executive summary
3
Chapter 1 Water is life
The historical context
4
The institutional context
7
The focus of this report
10
Part 1
The Millennium Development target for domstic

water supply and sanitation
13
Chapter 2 Why focus on water supply and sanitation?

Human values and human rights
15
Contribution to the Millennium Development Goals
17
15
Chapter 3 Target 10 and the global monitoring system

Target 10 on water and sanitation
31
The current system for monitoring and evaluation
33
28
Chapter 4 Where are the needs greatest?

38
Access to domestic water supply and sanitation services
39
Current levels of access and the rate of progress toward the goal
Low access to services and high incidence of water-related disease
41
42
vi
Contents
Identifying greatest needs globally

44
Pinpointing greatest needs within countries
Chapter 5 Whats holding us back?
Political constraints
62
Institutional constraints
64
Financial constraints
69
Technical challenges
74
Conclusion
77
45
62
Chapter 6 The special challenge of meeting the sanitation target

A collective or an individual service?
80
The nature of demand for improved sanitation
81
Reorienting public institutions for sanitation service delivery
83
Changing roles for government
85
New technologies or better use of existing technologies?
87
Alternative planning approaches for urban sanitation
88
Alternative planning approaches for rural sanitation
90
Galvanizing support for sanitation and hygiene
91
Chapter 7 Technology and infrastructure
Available technological options
93
Cost-reduction strategies
98
The need for innovation
100
Chapter 8 What would it cost?
102
Global estimates
102
National estimates: a method to assess needs
93
103
Chapter 9 Grappling with nancing for the poorest

113
Principal target group: poor people in the poorest countries
114
Financial constraints in low-income countries
115
Affordability, sustainability, and water conservation
122
What about middle-income countries?
123
Part 2
Water resources for all the Millennium

Development Goals
125
Chapter 10
Why does water resources development

and management matter?
127
Poverty and hunger
128
Environmental sustainability
133
Health
136
79
Contents
vii
Gender equality
137
Exploiting potential synergies through combined approaches
Chapter 11 What actions are needed?
142
Investing in water resources development and management
Adopting integrated water resources management
147
Examples of context-specic actions
148
138
146
Chapter 12 Monitoring and support systems

151
Monitoring water resources
151
Global institutional support structures
156
Recommendations for the international community
157
Part 3
Achieving the Millennium Development Goals
Chapter 13 How to make the Goals a reality

A call to action
163
Ten critical actions
165
Chapter 14
An operational plan
Appendix 1
Insights from case studies
161
163
174
180
Notes
194
References
200
Boxes
1.1
1.2
2.1
2.2
2.3
2.4
2.5
2.6
2.7
3.1
5.1
Millennium Development target 10

4
Lessons from the International Drinking Water Supply and Sanitation
Decade
9
Lack of sustainable access to basic sanitationa polite way to say
open defecation
16
Economic benets from improving water supply and sanitation
services
19
Maximizing the health benets from water supply, sanitation, and
hygiene interventions
20
Where does hygiene t in?
24
Household water treatment and safe storage
24
How long are we going to live this way?
25
Modest dreams
26
What is sanitation?
30
Water is a political issue
63
viii
Contents
5.2
6.1
8.1
10.1
10.2
10.3
10.4
10.5
10.6
10.7
10.8
12.1
Overcoming constraints and increasing access: the South African

experience
77
Unheard voices of women
82
Assumptions used in arriving at the estimates in table 8.1
103
Water-related disasters: facts from the World Health
Organization
127
Improving water management to spur economic
development
128
Main water-related recommendations of the Millennium Project for
meeting the poverty and hunger Goals
130
Main water-related recommendations of the Millennium Project Task
Force on Environmental Sustainability
133
Living with urban environmental problems
134
Force on Improving the Lives of Slum Dwellers
135
Malaria: facts from the World Health Organization
136
Force on Education and Gender Equality
137
The evolution of interagency coordination in water resources and
sanitation
157
Figures
3.1
4.1
5.1
5.2
5.3
5.4
6.1
Millennium Development Goals for water and sanitation reach the

neediest in urban and rural areas
33
A typology of communities with low water supply and sanitation
coverage
45
Access to water supply rises as national income rises
69
The richest are twice as likely to use drinking water from an improved
source as the poorest
70
The richest are four times more likely to use improved sanitation than
the poorest
70
Private investment in infrastructure has fallen off in recent
years
72
Urban water and sanitation services are much more expensive than
simpler rural services
89
Maps
4.1
4.2
4.3
11.1
Regional groupings for the Joint Monitoring Programme

39
Prevalence of diarrhea and improved water supplies, 2000
43
Prevalence of diarrhea and improved sanitation, 2000
44
Water stress in major river basins
145
Contents
ix
Tables
2.1
3.1
4.1
4.2
4.3
4.4
4.5
4.6
7.1
7.2
7.3
8.1
8.2
8.3
9.1
9.2
9.3
9.4
10.1
14.1
14.2
14.3
14.4
14.5
14.6
14.7
14.8
Contribution of access to domestic water supply and sanitation to the

Millennium Development Goals
18
Improved and unimproved water and sanitation facilities
29
Access to improved drinking water sources by region, 2002
40
Access to improved sanitation by region, 2002
40
Number of people to whom access must be extended by 2015 to meet
target 10
41
High-need countries identied by various criteria
46
Typology of unserved and underserved communities for water
supply
55
Typology of unserved and underserved communities for
sanitation
60
Water supply technologies
94
Selected technological options for sustainable access to
sanitation
95
Water and sanitation service levels
97
Cost estimates for reaching the Millennium Development targets for
water supply and sanitation, 200515 (billions of dollars)
103
Resource requirements for reaching target 10 in Ghana,
200515
110
Resource requirements for reaching target 10 in ve low-income
countries, 200515
111
Unserved people: where are they?
114
Distribution of the global population without access to safe water
supply
115
Distribution of the global population without access to basic
sanitation
115
Potential domestic resource mobilization for the Millennium
Development Goals
119
Contribution of improved water resources management to the
129
Priority actions for national and subnational governments
176
Priority actions for bilateral and multilateral development assistance
agencies
177
Priority actions for the United Nations system
177
Priority actions for service providers
178
Priority actions for civic and community organizations
178
Priority actions for international networks and partnerships
178
Priority actions for research organizations
179
Priority actions for all actors throughout the Millennium
Development process and beyond
179
Task force members
Task force coordinators
Roberto Lenton, The Earth Institute at Columbia University

Albert M. Wright, Independent consultant
Task force members
Ingvar Andersson, Senior Freshwater Advisor, United Nations Development

Program (through June 2004)
Jamie Bartram, Coordinator, Water, Sanitation and Health Programme,
World Health Organization (permanent observer as chair of UN-Water
and on behalf of WHO)
Margaret Catley-Carlson, Chair, Global Water Partnership; Chair, International Center for Agricultural Research in Dry Areas
Ivan Cheret, Independent consultant, Paris
Kamla Chowdhry, Chair, Vikram Sarabhai Foundation, New Delhi
Bill Cosgrove, President, World Water Council (through December 2004)
Jennifer Davis, Professor of Development Planning, Massachusetts Institute
of Technology, Cambridge, Mass.
Manuel Dengo, Chief, Water and Natural Resources, United Nations Department of Economic and Social Affairs
Halifa Drammeh, Deputy Director, Division of Policy Development and
Law, United Nations Environment Programme
Gourisankar Ghosh, Executive Director, Water Supply and Sanitation Collaborative Council
Mi Hua, Sanitation Specialist, UN Millennium Project Technical Support
Centre, Nairobi
Hans Olav Ibrekk, Adviser, Norwegian Agency for Development Cooperation, Oslo
Task force members
xi
Sir Richard Jolly, Fellow, Institute for Development Studies, University of

Sussex, United Kingdom
Torkil Jonch-Clausen, Senior Advisor, Global Water Partnership, Copenhagen
Mike Muller, Director General, South Africa Department of Water Affairs,
Pretoria
Dennis Mwanza, Managing Director, Water Utility Partnership, Dakar
Ravi Narayanan, Director, WaterAid, London
Noma Nyoni, Deputy Director, Institute of Water and Sanitation Development, Harare
Kalyan Ray, Chief, Building and Infrastructure Technology, United Nations
Human Settlements Programme
Frank Rijsberman, Director General, International Water Management Institute, Colombo
Jamal Saghir, Director, Energy and Water, World Bank
David Seckler, Independent consultant, Greeley, Colo.
Vanessa Tobin, Chief, Water, Environment and Sanitation, United Nations
Childrens Fund
Gordon Young, Coordinator, World Water Assessment Programme
Task force secretariat
Kristen Lewis, Senior Policy Advisor and Task Force Manager

Christie Walkuski, Administrative Assistant
Other key contributors
Barbara Evans, Independent consultant, Maccleseld, U.K.

Guido Schmidt-Traub, Policy Advisor, UN Millennium Project
Susmita Shekhar, Senior Vice President, Sulabh International Social Service
Organization, New Delhi
Preface
At the United Nations Millennium Summit in September 2000, the largestever gathering of world leaders adopted the Millennium Declaration. From the
Declaration emerged the Millennium Development Goals, an integrated set of
time-bound targets for extending the benets of globalization to the worlds
poorest citizens and making real progress, by 2015, in tackling the most pressing issues facing developing countries.
Among those targets is Millennium Development target 10: to cut in half,
by 2015, the proportion of people without sustainable access to safe drinking
water and basic sanitation. In addition, sound water resources management
and development is a key to achieving all of the Goals.
To help the international community as a whole reach the Millennium
Development Goals, the UN secretary-general and the administrator of the
United Nations Development Programme (as chair of the United Nations
Development Group) commissioned the UN Millennium Project, as an independent advisory body. The UN Millennium Project was a three-year effort
to identify the best strategies for meeting the Goals. Ten task forces, each one
focused on a specic substantive area and made up of independent experts
from the relevant disciplines and sectors, performed the bulk of the UN Millennium Projects work; each task force was responsible for identifying what it
would take to achieve one or more of the targets.
Whats new about this report?
In the past 25 years, a number of commissions, expert groups, and high-level

panels have produced reports and recommendations on water and sanitation.
Indeed, many task force members have themselves been involved in these valuable exercises, and in our work we have deliberately sought not to reinvent the
wheel, but rather to build on past efforts and ongoing processes.
Preface
xiii
The UN Millennium Project Task Force on Water and Sanitation, together

with the larger UN Millennium Project, of which it is an integral part, represented a unique opportunity to tackle two tasks that have heretofore not been
undertaken: Identifying what it will take to meet the targets on water and sanitation, including pinpointing the actions needed in other sectors; and identifying the actions needed in the water resources sector to meet the Millennium
Development Goals as a whole. In building on the excellent work of previous
bodies, therefore, the task force has brought two new dimensions to the table.
First, it has set out to answer a very different question from that addressed
by previous initiatives: given the urgency of achieving the Goals and the
repeated international commitments to achieve them, what specic policies
and resources are needed to meet the Goals, and who needs to take responsibility for ensuring they are in place?
Second, it has identied the specic policies and resources needed to meet
the Goals as part of a larger UN Millennium Project. Therefore, the task
force could not only determine the actions needed in the water sector within
a broader context but also pinpoint the actions needed in other sectors if the
targets on water and sanitation are to be met. This broad context is critical,
given that advances in a number of areasfrom poverty reduction to gender
equality to improvements in the international terms of tradestrongly affect
the ability of countries to meet the water and sanitation target and to optimize
water use.
Other characteristics that differentiate the report include:
Its ability to dovetail an action plan for water in the larger context of
action plans to achieve the Millennium Development Goals.
The authority and visibility that comes from its association with the
UN Millennium Project.
The intellectual independence that has been granted to the UN Millennium Project, as well as the analytical strength that derives from the
projects overall framework and methodology.
The overall international context of support for the Goals.
This document, the nal report of the task force, is intended primarily
for the policy and technical communities concerned with the achievement of
the Goals, particularly target 10, in governments, international organizations,
bilateral donor agencies, specialized nongovernmental organizations, water
agencies, and academia. We have sought to strike a balance between providing
sufcient background information to make the report accessible to the nonexpert and maintaining a focus on what it will take to achieve the Goals.
Denitions
Since the term water in the name of the task force embraces both domestic
water supply (as in target 10) and water resources management, we attempt
throughout the report to use terminology that clearly differentiates the term
xiv
Preface
in each case. Thus, we employ the terms domestic water supply and sanitation
services or simply water supply and sanitation when we refer to water and sanitation in the context of target 10. We use the terms water resources management,
water as a resource, or simply water resources when we refer to the management
of water as a resource for meeting the Goals as a whole, including the infrastructure needed to manage the resource. We use the term water resources development and management to mean the infrastructure, governance, and management measures required to manage and control freshwater to meet human and
environmental needs. We use the overall terms water or water and sanitation
only when we explicitly wish to embrace both domestic water supply and water
resources management. We dene safe drinking water as water that is safe to
drink and available in sufcient quantities for hygienic purposes. Our working denition of basic sanitation is the lowest-cost option for securing sustainable access to safe, hygienic, and convenient facilities and services for excreta
and sullage disposal that provide privacy and dignity while ensuring a clean
and healthful living environment both at home and in the neighborhood of
users.1
Acknowledgments
This nal report is the culmination of three years of analysis, consultation

with others, and substantial debate and interchange among the members of
the task force. Task force members met in Delhi, Nairobi, New York, and
Stockholm from October 2002 to September 2004 and frequently exchanged
views through numerous electronic discussions. The report draws heavily on
the interim report prepared by the task force in December 2003 and incorporates the feedback received from various sources. It also incorporates material
from several analyses that the task force commissioned in early 2004 with support from the government of Norway.
The members of the task force have contributed actively and in their personal capacity to the work of the group, whose conclusions are embodied in
this report. The views expressed do not necessarily reect those of the organizations with which task force members are afliated.
This nal report is complemented by a companion short documentthe
nal report, abridged editionwhich serves as both a free-standing statement
of the main recommendations and an executive summary. The document in
hand contains considerable additional material substantiating the principal
arguments in the abridged report, but no change in the argument itself.
This report has been prepared by a small writing and editing team consisting
of Kristen Lewis, senior policy advisor and task force manager, and ourselves.
As task force coordinators, we wish to express a special appreciation to Kristen
Lewis, whose superb writing skills, ability to understand and communicate
the big picture, capacity to address the very large number of issues raised by
task force members and external reviewers on the various drafts of this report,
and constant energy and enthusiasm have proved absolutely invaluable to task
force members and ourselves alike. We also thank Christie Walkuski for her
generous assistance in the preparation of the report, including the annexes and
xvi
Acknowledgments
gures, with unfailing good humor under signicant time pressure, and for
her consistent support to the task force throughout the entire project. The nal
report was edited and produced by Meta de Coquereaumont, Carol Rosen,
Bruce Ross-Larson, Christopher Trott, and Elaine Wilson of Communications
Development Incorporated.
We also wish to acknowledge, with thanks, the extensive contributions of
several people and organizations to the development of this report. In particular, we would like to thank Guido Schmidt-Traub of the UN Millennium Project for the section on the projects needs assessment methodology, as well as
for his gracious, unagging, and truly invaluable support throughout the life
of the task force; Jennifer Davis, task force member, for her work to devise the
community typology outlined in the report and her extensive contributions,
particularly to chapters 5 and 6 and the plan of action; Mi Hua, task force
member, for her contributions to chapters 6 and 8; Barbara Evans, independent consultant, for her work preparing a background paper that formed the
basis for chapter 6; Michael Krause and Alice Wiemers of the UN Millennium
Project Secretariat for assistance in data analysis; Adam Storeygard and Marc
Levy of CIESIN for their assistance in the preparation of maps in chapter 4;
Jon Lane, Judith Rees, and Peter Rogers for their insightful comments as external reviewers of an advanced draft of the report; and Anupa Fabian for a heroic
marathon of fact-checking in the nal days. In addition, we greatly appreciated the contributions of the UN Human Settlements Programme, the UN
Department of Economic and Social Affairs, the United Nations Development Programme, the United Nations Environment Programme, the United
Nations Childrens Fund, the World Bank, and the World Health Organization, whose documents we drew on extensively in several parts of this report
and whose staff assisted us in numerous ways.
Finally, the report could not have been written without the task force members and other key contributors listed in the preceding pages: their tremendous
efforts, wealth of knowledge and expertise, personal dedication to the issues,
and commitment to creating a consensus document made our work together
deeply rewarding. The coordinators take full responsibility for any errors or
omissions in the contents of this report.
Roberto Lenton and Albert Wright
Task force coordinators
xviii
xix
Executive summary
Four of every ten people in the world do not have access to even a simple pit
latrine; and nearly two in ten have no source of safe drinking water. This
silent humanitarian crisis kills some 3,900 children every day; thwarts progress
toward all the Millennium Development Goals, especially in Africa and Asia;
and robs the poorestparticularly women and girlsof their health, time,
and dignity. Water supply and sanitation services, as well as water as a resource,
are critical to sustainable developmentfrom environmental protection and
food security to increased tourism and investment, from the empowerment of
women and the education of girls to reductions in productivity losses due to
morbidity and malnutrition.
The UN Millennium Project Task Force on Water and Sanitation sought
to answer two questions: what will it take to expand water supply and sanitation coverage dramatically and sustainably? How can the use of water as a
resource be optimized to achieve the Millennium Development Goals?
At the conclusion of its three-year project, the task force was unanimous in
its belief that the water and sanitation target, to halve, by 2015, the proportion
of people without sustainable access to safe drinking water and basic sanitation, will not be reached unless:
There is a deliberate commitment by donors to increase and refocus
their development assistance and to target sufcient aid to the poorest
low-income countries.
There is a deliberate commitment by governments of middle-income
countries that do not depend on aid to reallocate their resources so that
they target funding to their unserved poor.
There are deliberate activities to create support and ownership for water
supply and sanitation initiatives among both women and men in poor
communities.
Executive summary
There is a deliberate recognition that basic sanitation in particular

requires an approach that centers on community mobilization and
actions that support and encourage that mobilization.
Furthermore, our group is convinced that the Millennium Development
Goals as a whole will not be met unless:
There is deliberate planning and investment in sound water resources
management and infrastructure.
The task force identied 10 critical actions for achieving the water and
sanitation target and fostering the sound management of water resources for
all the Goals. They are:
Action 1. Governments and other stakeholders must move the sanitation
crisis to the top of the agenda.
Action 2. Countries must ensure that policies and institutions for water
supply and sanitation service delivery, as well as for water resources management and development, respond equally to the different roles, needs, and priorities of women and men.
Action 3. Governments and donor agencies must simultaneously pursue
investment and reforms.
Action 4. Efforts to reach the water and sanitation target must focus on
sustainable service delivery, rather than construction of facilities alone.
Action 5. Governments and donor agencies must empower local authorities and communities with the authority, resources, and professional capacity
required to manage water supply and sanitation service delivery.
Action 6. Governments and utilities must ensure that users who can pay do
pay in order to fund the operation, maintenance, and expansion of services
but they must also ensure that the needs of poor households are met.
Action 7. Within the context of national poverty reduction strategies based
on the Millennium Development Goals, countries must elaborate coherent
water resources development and management plans that will support the
achievement of the Goals.
Action 8. Governments and their civil society and private sector partners
must support a wide range of water and sanitation technologies and service levels that are technically, socially, environmentally, and nancially appropriate.
Action 9. Institutional, nancial, and technological innovation must be
promoted in strategic areas.
Action 10. The United Nations system organizations and their member
states must ensure that the UN system and its international partners provide
strong and effective support for the achievement of the water supply and sanitation target and for water resources management and development.
Chapter 1
Water is life
Water is life for people and for the planet. It is essential to the well-being
of humankind, a vital input to economic development, and a basic requirement for the healthy functioning of all the worlds ecosystems. Clean water
for domestic purposes is essential for human health and survival; indeed, the
combination of safe drinking water, adequate sanitation, and such hygienic
practices as hand washing is recognized as a precondition for reductions in
morbidity and mortality rates, especially among children.
Water is also critical to other facets of sustainable developmentfrom environmental protection and food security to increased tourism and investment,
from the empowerment of women and the education of girls to reductions in
productivity losses due to illness and malnutrition. Thus, increasing access to
domestic water supply and sanitation services and improving water resources
management are catalytic entry points for efforts to help developing countries
ght poverty and hunger, safeguard human health, reduce child mortality, promote gender equality, and manage and protect natural resources. In addition,
sufcient water for washing and safe, private sanitation facilities are central to
the basic right of every human being for personal dignity and self-respect.
For the worlds poorest citizens, however, the right to safe water and adequate
sanitation remains a promise unfullled. At least 1.1 billion people lack access
to safe water, and 2.6 billion lack access to basic sanitation, a silent humanitarian crisis that each day takes thousands of lives, robs the poor of their health,
thwarts progress toward gender equality, and hamstrings economic development, particularly in Africa and Asia (WHO/UNICEF JMP 2000).
Every year millions of people, most of them children, die from diseases
associated with inadequate water supply, sanitation, and hygiene (WHO
2004a). According to the World Health Organization, each and every day
some 3,900 children die because of dirty water or poor hygiene; diseases trans-
Chapter 1
For the
worlds
poorest
citizens, the
right to safe
water and
adequate
sanitation
remains a
promise
unfullled
Water is life
mitted through water or human excrement are the second-leading cause of

death among children worldwide, after respiratory diseases (WHO 2003).
Water scarcity, poor water quality, and inadequate sanitation negatively impact
food security, livelihood choices, and educational opportunities for poor families across the developing world. The current gulf in water use between rich
and poor countries is widepeople in industrialized countries use 3050
times more water than people in developing countries (UN/WWAP 2003).
Yet, although far more people suffer the ill effects of poor water supply and
sanitation services than are affected by such headline-grabbing topics as war
and terrorism, those issues capture the public imaginationas well as public
resourcesin a way that water and sanitation issues do not.
Water challenges will increase signicantly in the coming years. Continuing population growth and rising incomes will lead to greater water consumption, as well as more waste. The urban population in developing countries will
grow dramatically, generating demand well beyond the capacity of already
inadequate water supply and sanitation infrastructure and services. By 2050, at
least one in four people is likely to live in a country affected by chronic or recurring shortages of freshwater (UN/WWAP 2003). This may seriously constrain
the availability of water for all purposesparticularly for agriculture, which
currently accounts for 70 percent of all water consumed (UN/WWAP 2003).
The world is waking up to the water and sanitation crisis. At the United
Nations Millennium Summit in September 2000, the largest-ever gathering
of world leaders adopted the Millennium Declaration; from the Declaration
emerged the Millennium Development Goals, an integrated set of time-bound
targets for extending the benets of globalization to the worlds poorest citizens.1 Among them was target 10, to cut in half the proportion of people without sustainable access to safe drinking water (box 1.1). At the World Summit
for Sustainable Development in 2002, this target was expanded to include
basic sanitation, and water as a resource was recognized as a critical factor for
meeting all the Goals.2
The historical context
The goals and targets relating to water and sanitation outlined in the United
Nations Millennium Declaration and in the Millennium Development Goals
and targets were not developed in a vacuum. Indeed, they were the culmination of several decades of international deliberations on the subject.
Box 1.1
Millennium
Development
target 10
To halve, by 2015, the proportion of people without sustainable access to safe drinking
water and basic sanitation.
Chapter 1
The world is
waking up to
the water and
sanitation
crisis
Water is life
International conferences and agreements on water and sanitation

Over the past 30 years numerous conferences and international agreements have
provided the broad background for todays water resources policies and decisionmaking (UN WEHAB Working Group 2002).3 In the past decade many
international conferences have discussed and agreed on steps required to speed
up the implementation of Agenda 21, a comprehensive plan of action for sustainable development adopted by more than 178 governments at the United Nations
Conference on Environment and Development (UNCED) held in Rio de Janeiro
in 1992. Water for sustainable development was discussed at the intergovernmental level in the sixth session of the Commission on Sustainable Development
in 1998, and broad consensus was reached on key water issues; further international water meetings (such as the Second World Water Forum in the Hague in
2000 and the International Conference on Freshwater in Bonn in 2001) served
as important forums for multistakeholder dialogues and generated new recommendations on how to address increasing water challenges. The United Nations
Millennium Declaration and the preparatory process leading up to the World
Summit on Sustainable Development further afrmed the role of water as a key
to sustainable development and the urgency of immediate action.
The Millennium Declaration and the Goals and targets relating to water
and sanitation
Water and sanitation are dealt with in several ways in the United Nations Millennium Declaration and in the nal list of Millennium Development Goals
and targets (UN General Assembly 2000).4
In chapter 4 (Sustaining Our Future) of his report to the Millennium
Summit the secretary-general urged the Summit to adopt the target of reducing by half, between now and 2015, the proportion of people who lack sustainable access to adequate sources of affordable and safe water (UN 2000). In
the Millennium Declaration the heads of state gathered at United Nations
Headquarters in New York in September 2000 resolved, under the heading
protecting our common environment,
To stop the unsustainable exploitation of water resources by developing
water management strategies at the regional, national, and local levels,
which promote both equitable access and adequate supplies.
This resolution is explicitly highlighted as a goal in the secretary-generals
report to the UN General Assembly on the follow up to the outcome of the
Millennium Summit (UN 2001, p. 34). In the statement of the United Nations
Millennium Development Goals and targets, however, the overall goal relevant
to this area (Goal 7) is stated more generally as ensuring environmental
sustainability, with three specic targets:
Integrate the principles of sustainable development into country policies
and programs; reverse loss of environmental resources.
Chapter 1
Further
international
deliberations
on water and
sanitation
have helped
advance
cooperation
and action
Water is life
Halve by 2015 the proportion of people without sustainable access to

safe drinking water and basic sanitation.
Achieve signicant improvement in the lives of at least 100 million slum
dwellers by 2020.
Two conclusions can be drawn: rst, the goal of stopping the unsustainable
exploitation of water resources by developing water management strategies at
the regional, national, and local levels, which promote both equitable access and
adequate supplies appears to have been incorporated in that part of the rst
target that refers to reversing the loss of environmental resources. Second, the
target urged by the secretary-general in his report to the Millennium Summit
was incorporated (with some modications) in the second target to reduce by
half the proportion of people without sustainable access to safe drinking water.
The World Summit on Sustainable Development
One of the main outcomes of the World Summit on Sustainable Development
(WSSD) in September 2002 was that water and sanitation were recognized as
being inextricably linked to the eradication of poverty and to the achievement
of sustainable development (UNDESA 2002b).5 Water was identied by the
secretary-general as one of the ve specic WEHAB areas (water, energy,
health, agriculture, and biodiversity) in which concrete results are both essential and achievable. To provide focus and impetus to action on water issues,
a document entitled A Framework for Action on Water and Sanitation was
prepared for WSSD; it outlined the larger context in which the targets were
established and provided a holistic view of the multiple impacts of increasing
sustainable access to water supply and sanitation by the poor (UN WEHAB
Working Group 2002).
WSSD reiterated the Millennium Development Goal to halve, by 2015,
the proportion of people who are unable to reach or to afford safe drinking
water and to set a new target on halving the proportion of people who do not
have sustainable access to basic sanitation. This sanitation objective is now an
integral part of target 10.
Several elements for a program of action on sanitation were clearly established in the WSSD Plan of Implementation (UNDESA 2002a), which particularly highlighted the need to incorporate sanitation within strategies for
integrated water resources management. The water and sanitation targets are
set out under the Plan of Implementation chapters on poverty eradication and
protecting the natural resource base. Water resource management and protection were also recognized as fundamental to sustainable management of the
natural resource base for economic and social development. It was also recommended that the participation of women be facilitated at all levels in support
of policies and decisionmaking related to water resources management and
project implementation. Water-related policies were included in virtually all of
the natural resource objectives of the Plan of Implementation.
Chapter 1
There is a
very dynamic
process of
advancing
international
understanding
and
cooperation
on water for
sustainable
development
Water is life
Notably, the Plan of Implementation took a broad view of the actions

required to achieve the Millennium Development Goal on water and sanitation,
emphasizing the need, for example, to intensify water pollution prevention to
reduce health hazards and protect ecosystems, and to adopt measures to promote
sustainable water uses and address water shortages. The plan made a strong call
for integrated water resources management by setting a new time-bound target to develop integrated water resources management and efciency plans by
2005, with support to developing countries, through actions at all levels.
Developments following the summit
Since Johannesburg, further international deliberations on water and sanitation have helped advance cooperation and action in this area. In late 2002, the
United Nations afrmed the Right to Water, noting that such a right is indispensable for leading a life in human dignity and a prerequisite for the realization of other human rights. In early 2003 water and sanitation (together with
human settlements) were selected as the rst themes to be discussed systematically by the Commission on Sustainable Development in the post-WSSD era,
and became the focus of review and policy discussions of the UN Commission on Sustainable Development in 2004 and 2005. The Third World Water
Forum in Kyoto, Japan, in March 2003 and the International Conference on
Water for the Poorest in Stavanger, Norway, in November of that year also
drew further attention to the subject.
In late 2003 the UN General Assembly adopted a resolution that proclaimed the period 200515 as the International Decade for ActionWater
for Life (UN General Assembly 2004). The decade will ofcially start on
World Water Day, March 22, 2005. Goals for the decade will be a greater focus
on water-related issues and for actions to ensure the participation of women in
water-related development efforts. Focus will also be on furthering cooperation
at all levels, so that the water-related goals of the Millennium Declaration, the
Johannesburg Plan of Implementation of the World Summit for Sustainable
Development, and Agenda 21 can be achieved. The resolution emphasized
that water is critical for sustainable development, including environmental
integrity and the eradication of poverty and hunger, and is indispensable for
human health and well-being.
The institutional context
Although there is no global, comprehensive, intergovernmental structure for

water, there is a very dynamic process of advancing international understanding and cooperation on water for sustainable development. These efforts are
led by different governments; by the private sector and members of the civil
society; by the work of various UN system entities and by other important
regional and intergovernmental bodies; by such NGOs as WaterAid; and by
several organized networks or partnerships, such as the Water Supply and
Chapter 1
Water
services are
often most
effectively
delivered
through
decentralized
organizations
Water is life
Sanitation Collaborative Council (WSSCC) and its WASH (Water Sanitation

and Hygiene for All) partnership, the Global Water Partnership (GWP), the
Gender and Water Alliance, and the World Water Council. Progress on water
for sustainable development requires by its very nature a multistakeholder
approach (UN WEHAB Working Group 2002).
Within the UN system, a number of different entities are involved in water
and sanitation-related issues. Perspectives and approaches vary according to
the mission and mandates that the governing bodies provide to the different UN entities. These entities have recently formed UN-Water, the United
Nations Inter-Agency Committee on Water Resources, which was formally
established as the interagency mechanism for follow-up of the WSSD waterrelated decisions and the Goals concerning freshwater in 2003. The way in
which the international community as a whole currently supports water and
sanitation issues is discussed in greater detail in chapter 12.
Global strategies, frameworks, and plans of action
The development of global plans or frameworks for action has been an inherent part of the process of advancing international cooperation on water and
sanitation, starting with the International Drinking Water Supply and Sanitation Decade (box 1.2). Other important frameworks for action on water or
sanitation since the decade ended include:
The Dublin Statement and Report of the Conference on Water and
Environment (1992).
Towards Water Security: A Framework for Action prepared by the
Global Water Partnership to achieve the Vision for Water in the Twentyrst Century (2000).
Framework for Action outlined in the WSSCCs document, Vision
21: A Shared Vision for Hygiene, Sanitation, and Water Supply and A
Framework for Action (2000).
Numerous national and community level plans prepared under Vision
21s umbrella.
Bonn Plan of Action (2001).
Framework for Action on Water and Sanitation prepared by the
WEHAB Working Group for the World Summit on Sustainable Development (2002).
Most of these plans and frameworks for action, however, have fallen short
of a full strategy, in that they do not lay out the organizational means required
for implementation, nor provide clarity on the amount, nature, and sources of
nancing required.
Local institutions
It is widely recognized that water services are often most effectively delivered through decentralized organizations and that voluntary community
Chapter 1
Water is life
participation is critical to their success. Many institutions of local governance

that now have a broader role were initially established to manage water. Aside
from the ancient riverine civilizations of Asia and Africa, local governments in
Box 1.2
Lessons from
the International
Drinking Water
Supply and
Sanitation Decade
Source: Drawn from
material contributed
by task force member
Gouri Ghosh.
The Mar del Plata United Nations Conference on Water held in 1977 was the rst intergovernmental conference devoted exclusively to water, a milestone in the history of water
development. As a result of the Mar del Plata action plan, the United Nations General
Assembly in 1980 proclaimed the period 198190 as the International Drinking Water
Supply and Sanitation Decade (IWSSD). The IWSSD was a period of accelerated and
concerted effort to expand water supply and sanitation services to the unserved and
underserved poor populations, spearheaded by a group of UN agencies (UNICEF, WHO,
and UNDP) and the World Bank. The ofcial reporting of progress was entrusted to WHO.
The Interagency Steering Committee for Co-operative Action for the International Drinking
Water Supply and Sanitation Decade succeeded in improving the coordination and cooperation among the multilateral and bilateral agencies participating.
Although the IWSSD did not reach its goal of total access in quantitative terms, much
was learned from the experience of the IWSSD, including the further realization of the
importance of partnerships, advocacy, knowledge dissemination, and comprehensive and
balanced country-specic approaches to water and sanitation. Most important, perhaps,
was the realization that the achievement of the goal would take far more time and cost far
more money than was originally thought. Throughout the decade international organizations and bilateral donors developed a highly qualied group of dedicated water professionals, and water and sanitation were high on the development cooperation agenda.
As a result of the IWSSD new partnerships were developed, including the UNDPWorld
Bank Water Supply and Sanitation Programme (now the Water and Sanitation Programme),
administered by the World Bank and funded by many bilateral donors, and the Water Supply and Sanitation Collaborative Council (WSSCC). The UN General Assembly resolution in
December 1990 at the end of the decade emphasized the importance of intensifying the
coordination of national activities undertaken with the assistance of all relevant agencies
in the eld of water supply and sanitation, in particular through the interagency group and
the WSSCC. The WSSCC is a unique experiment of partnership within the UN system,
providing an open platform to civil society, government, private sector, and research institutions to come together.
The Global Consultation for Safe Water 2000 held in New Delhi, September 1990, drew
lessons from the decade, resulting in the New Delhi Statement: Some for all rather than
more for some. At the World Summit for Children in 1990, the goal of universal access
to safe water and sanitation by the year 2000 was adopted to promote the survival,
protection, and development of children. The 1992 International Conference on Water
and the Environment, held in Dublin, developed four principles for water management
and put integrated water resources management on the political agenda. The importance
of universal access to drinking water supply and sanitation was further reiterated at the
1992 United Nations Conference on Environment and Development. There, world leaders endorsed Agenda 21s recommendations on the protection of freshwater resources.
Thereafter, many other crucial international conferences recognized water and sanitation
as the bedrock of public health and social progress and the key to improving peoples
survival, health, and development, including the World Summit on Sustainable Development in 2002.
10
Chapter 1
It is
necessary to
recognize the
plurality of
institutions
and to clarify
their roles,
relationships,
and
sequence of
development
Water is life
European countries, such as the Netherlands and Great Britain, were rooted in
the need to cooperate to manage water on a collective basis in the public interest. This perspective is important not just for the design of water strategies, but
also to provide an institutional framework for the achievement of other Goals
(Muller 2004).
It is also necessary to recognize the plurality of institutions of local government and voluntary community participation and to clarify their roles, interrelationships, and sequence of development. Critical as well is understanding
the different roles and responsibilities of men and women in water supply and
sanitation provision, as well as recognizing that other factors, such as socioeconomic status, ethnicity, and age may place additional burdens on women in
water resources management.
The focus of this report
In preparing this report, the Task Force on Water and Sanitation had a dual
role. It focused on how to identify and communicate the strategies and actions
needed to accomplish Millennium Development target 10 to cut in half, by
2015, the proportion of people without sustainable access to safe drinking water
and basic sanitation; it also examined the requirements for water resources management and development posed by all of the Millennium Development Goals.
For water supply and sanitation, it was responsible for identifying priority areas
for action, developing strategies, proposing effective institutional arrangements
for addressing these areas, and exploring both nancial requirements and possible new sources of funding. For water resources management and development, its principal objective was to identify and communicate the water-related
actions and strategies required to help achieve the Goals as a whole.
The report is organized as follows:
Chapter 1 provides the context for the task forces work.
Part 1 focuses on target 10. It explains why it is important to focus
on domestic water supply and sanitation services, describes the Millennium Goals and targets related to water and sanitation, and provides a
brief summary of international discussions on water and sanitation. It
explores key issues that relate to the specic target for increasing sustainable access to water and sanitation, including current systems for
monitoring and evaluation. It provides an overview of progress toward
achieving the target on sustainable access to water and sanitation,
including a brief review of existing information on costs. In addition,
it examines constraints to meeting the target at the global, regional,
national, subnational, and community levels, as well as the types of
nancial, institutional, and technical reforms that are needed.
Part 2 explores issues related to water as a resource for achieving the
entire set of Millennium Development Goals. It includes a discussion
of the links between water resources management and specic Goals,
Chapter 1
Water is life
11
a review of the current institutional and monitoring apparatus at the

global level, a diagnosis and typology of the problems faced in various
parts of the world, and an examination of challenges to integrated water
resources management in support of the goals.
Part 3 outlines the task forces recommendations regarding the actions
needed to move forward. It also translates these overall recommendations into an operational plan, with specic actions that need to be
undertaken by key actors.
While the report focuses primarily on the water sector, the task force recognizes that reforms in other areas will have a strong impact on the ability
of countries to reach target 10 and to optimize water use. These issues are
addressed in Investing in Development: A Practical Plan to Achieve the Millennium Development Goals (2005), as well as in the reports of the other nine task
forces.
The Millennium Development

target for domestic water
supply and sanitation
Chapter 2
Why focus on water supply

and sanitation?
Given the myriad development challenges facing the worlds poorest countries and communitiesfrom the HIV/AIDS pandemic to pervasive gender
inequality and grinding povertywhy has halving the proportion of people
without sustainable access to safe drinking water and basic sanitation services
been singled out as critical? The imperative of dramatically expanding coverage of water supply and sanitation services and improving water management overall deserves the vigorous response of the international community
because of the relationship between water supply and sanitation, and questions
of human health, overall economic development, and equity, and because of
humankinds shared understanding of our responsibilities to one another, a
common understanding enshrined in many international human rights instruments (box 2.1). Not everyone will nd the various rationales for investment
in water supply and sanitation listed below to be equally persuasive. What
matters is that water supply and sanitation advocates, policymakers, and practitioners are able to articulate to a range of key constituencies a compelling case
for action and that governments and other important actors respond with the
necessary measures.
Human values and human rights
Expanding access to water and sanitation is a moral and ethical imperative

rooted in the cultural and religious traditions of societies around the world
and enshrined in international human rights instruments. Success in bringing water and sanitation to poor communities in the most difcult circumstances is due as much to the qualities and personal motivations of the people
concerned as it is to the technical ingenuity and the nancial resources available, important as those may be. Many services run on a shoestring of hope
by volunteers, religious groups, or dedicated, poorly paid ofcials succeed
16
Part 1
Many of
the most
effective
interventions
clearly
balance rights
and responsibilities
Box 2.1
Lack of
sustainable
access to basic
sanitationa
polite way to say
open defecation
Source: UN-HABITAT 2004.
The Milennium Development target for domestic water supply and sanitation
because they mobilize the enthusiasm and engagement of their communities,

while other projects backed by extravagant budgets and massive expertise
turn to dust in a bureaucratic desert that sties individual and community
spirit.
Many of the most effective interventions at the community level meld economic and social development with spiritual growth and bonds of communal
solidarity. They also clearly balance rights on the one hand with responsibilities
on the other; indeed, experience has shown that the most sustainable community-level interventions are characterized by signicant community investment
of labor, other in-kind resources, and user fees in the design, construction,
maintenance, and operation of facilities. The Millennium Development Goals
themselves are built around a shared understanding of what we as human
beings owe to one another and are informed by principles of fairness, justice,
and the obligation of the individual to pursue the mutual good that characterizes religious and ethical systems the world over.
These shared principles are echoed in the recent afrmation by the
United Nations of the Right to Water (November 26, 2002)a right that
is indispensable for leading a life in human dignity and a prerequisite
for the realization of other human rights. Through its General Comment
15, the Committee on Economic, Social, and Cultural Rights of the United
Nations Economic and Social Council stated that the human right to water
entitles everyone to sufcient, safe, acceptable, physically accessible, and
affordable water for personal and domestic uses. While the right to water
has been implicit in the rights to health, housing, food, life, and dignity
already enshrined in other international conventions, General Comment 15
is the rst to focus explicitly on the right to water and the responsibilities that
governments have in delivering clean water and adequate sanitation services
to all (ECOSOC 2002).
Early in the morning Vidya slips out of his shack on the banks of the Sabermati River and,
carrying a precious lot of water, hurries down to the dry riverbed. Weaving between the
excrement and rubbish he nds an open space and, in company with hundreds of other
men from his community, he defecates. It is a bit smelly and not very private, but he is
one of the lucky ones. For a start, his walk is short and safe, and his destination at least
has the advantage of a freshening breeze even at the height of summer. Others are far
less fortunate. As day breaks across the world precious hours are being wasted as men,
women, and children search for that elusive safe and secluded spot. Women, walking
farthest and often running the risk of attack, ridicule, and shame, pass young boys and
girls who will miss school today because there are no toilets. In the cities working women
are gearing up for a day with no chance of a toilet break, while men will have to nd any
available open space to the disgust of passing observers. All of them face repeated cases
of diarrhea, schistosomiasis, trachoma, and other water-related diseases. This is what it
means to have no sustainable access to basic sanitation.
Chapter 2
Why focus on water supply and sanitation?
17
Households
Contribution to the Millennium Development Goals
with access
Expanding access to domestic water supply and sanitation services, as called

for in target 10, will bring the international community closer to meeting a
number of other Millennium Development targets; in fact, for many of the
targets, it is difcult to imagine how signicant progress can be made without rst ensuring that poor households have a safe, reliable water supply and
adequate sanitation facilities.1 Meeting target 10 is particularly vital in terms
of the poverty, gender, and health Goals, and also has a signicant impact on
other Goals. For instance, as illustrated in table 2.1, in terms of the hunger
Goal, healthy people are better able to absorb the nutrients in food than those
suffering from excreta-related diseases, particularly intestinal worms; in terms
of the education goal, reducing the incidence of water and excreta-borne disease among children improves school attendance.
to safe,
reliable
domestic
water supply
and sanitation
services
are less
vulnerable
Poverty
At both the national and international levels, it is difcult to nd a denition
of poverty that is not based at least in part on access to safe drinking water
supply and basic sanitation services. For instance, the United Nations Development Programmes Human Poverty Index (UNDP 2003) is a composite of
indicators of basic dimensions of deprivation: a short life (measured by the percentage of people expected to die before 40), lack of basic education (measured
by literacy rates), and lack of access to, public and private resources (measured
by access to health services, clean water, and sanitation, and percentage of malnourished children under ve). Vulnerability is a critical dimension of poverty,
and households with access to safe, reliable domestic water supply and sanitation services are less vulnerable than those who must gure out on a daily basis
how to meet their needs.
Improved access to domestic water supply and sanitation brings with it
considerable economic benets at the household level (box 2.2). There is a
strong link between health and household livelihood security; the inadequate
water supply and sanitation services upon which the poor are forced to rely
damage their health, causing relatively high health costs relative to income, an
increase in morbidity, and a decreased ability to work. In addition, sufcient
water supply is critical to the success of many household-based microenterprises. Other links include the following:
Poor women and men spend a signicantly greater proportion of their
income on water than do the rich, and the absolute price they pay to
water vendors is often ten times or more the tap price.
Reducing the ill health and disease in children through improved
water supply and sanitation services frees the time of the adults who
care for them (particularly women) for more productive activities; it
also keeps the children themselves from missing school, which has longterm economic consequences. Less illness (among both children and
18
Part 1
Table 2.1
Contribution of access
to domestic water
to the Millennium
Development Goals
Millennium Goal
Contributions of domestic water supply and sanitation
Poverty
Household livelihood security rests on the health of its members;

adults who are ill themselves or who must care for sick children are
To halve the proportion of
less productive.
the worlds people whose
Illnesses caused by unsafe drinking water and inadequate sanitation
income is less than $1
generate health costs that can claim a large share of poor housea day
holds income.
Time spent collecting water cannot be used for other livelihood activities.
Hunger
To halve the proportion
of the worlds people who
suffer from hunger
Primary education
To ensure that children
everywhere complete
a full course of primary
schooling
Healthy people are better able to absorb the nutrients in food than
those suffering from water-related diseases, particularly worms,
which rob their hosts of calories.
Improved water supply and sanitation services relieve girls from water-fetching duties, allowing them to attend school.
Reducing illness related to water and sanitation, including injuries
from water-carrying, improves school attendance, especially for girls.
Having separate sanitation facilities for girls in schools increases
their school attendance, especially after menarche.
Gender equality
Community-based organizations for water supply and sanitation can

improve social capital of women.
To ensure that girls and
Reduced time, health, and care-giving burdens from improved water
boys have equal access
services give women more time for productive endeavors, adult eduto primary and secondary
cation, empowerment activities, and leisure.
education
Water sources and sanitation facilities closer to home put women
and girls at less risk for sexual harassment and assault while gathering water and searching for privacy.
Higher rates of child survival are a precursor to the demographic transition to lower fertility rates; having fewer children reduces womens
domestic responsibilities.
Child mortality
To reduce by two-thirds
the death rate for children under ve
Maternal mortality
To reduce by threefourths the rate of
maternal mortality
Major disease
Improved sanitation, safe drinking water sources, and greater quantities of domestic water for washing reduce infant and child morbidity
and mortality.
Sanitation and safe water in health-care facilities help ensure clean
delivery and reduce neonatal deaths.
Mothers with improved water supply and sanitation services are
better able to care for their children, both because they have fewer
illnesses and because they devote less time to water-fetching and
seeking privacy for defecation.
Accessible sources of water reduce labor burdens and health problems resulting from water portage, reducing maternal mortality risks.
Improved health and nutrition reduce susceptibility to anemia and
other conditions that affect maternal mortality.
Safe drinking water and basic sanitation are needed in health-care
facilities to ensure basic hygiene practices following delivery.
Higher rates of child survival are a precursor to the demographic transition toward lower fertility rates, and fewer pregnancies per woman
reduce maternal mortality.
Safe drinking water and basic sanitation help prevent water-related
diseases, including diarrheal diseases, schistosomiasis, lariasis,
trachoma, and helminthes. 1.6 million deaths per year are attributed
to unsafe water, poor sanitation, and lack of hygiene.
Improved water supply reduces diarrhea morbidity by 21 percent; improved sanitation reduces diarrhea morbidity by 37.5 percent; hand
washing can reduce the number of diarrheal cases by up to 35 percent;
additional improvements in drinking water quality, such as point-of-use
disinfection, would reduce diarrheal episodes by 45 percent.
To have halted and begun

to reverse the spread of
HIV, malaria, and other
major diseases
Environmental
sustainability
Adequate treatment and disposal of excreta and wastewater contributes to better ecosystem management and less pressure on freshwater resources.
To stop the unsustainable
exploitation of natural re- Improved sanitation reduces ows of human excreta into waterways,
helping to protect human and environmental health.
sources; to halve the proportion of people without Inadequate access to safe water and inadequate access to sanitation and other infrastructure are two of the ve dening characteriswater and sanitation; to
tics of a slum.
improve the lives of 100
million slum dwellers
Chapter 2
Box 2.2
Economic benets
from improving
water supply
and sanitation
services
Source: A summary of the
WHO report is available
at www.who.int/water_
sanitation_health/en/
execsummary.pdf.
19
A recent cost-benet analysis by the World Health Organization found that achieving the global
Millennium Development target on water and sanitation would bring substantial economic
gains: each $1 invested would yield an economic return of between $3 and $34, depending on the region. The benets would include an average global reduction of 10 percent in
diarrheal episodes. If the global water and sanitation target is met, the health-related costs
avoided would reach $7.3 billion per year, and the annual global value of adult working days
gained because of less illness would rise to almost $750 million. Better services resulting
from the relocation of a well or borehole to a site closer to user communities, the installation
of piped water supply in houses, and latrines closer to home yield signicant time savings.
The annual value of these time savings would amount to $64 billion if the target is met.
The total benets of such service improvements will vary across regions, as they
depend on the existing levels of water supply and sanitation coverage and the regionspecic levels of morbidity and mortality due to diarrheal diseases. Regions where the
number of unserved is high and the diarrheal disease burden signicant would realize the
greatest benets from improved services.
adults) means that adults miss fewer days of work, be it as employees,

entrepreneurs, or farmers, with positive impacts on overall income and
livelihood security. Each year in India, for example, 73 million working
days are lost to water-borne diseases at a cost of $600 million in terms
of medical treatment and lost production (UNDP 1981). Lower health
costs mean more disposable income.2
Access to water near the home can save signicant amounts of time for
women and girlstime that can be spent on productive activities and
education, which lay the groundwork for economic growth. Forty billion working hours are lost each year in Africa to the need to carry water
(Cosgrove and Rijsberman 1998), and improving domestic water supply
services reduces female time poverty.
Having healthier children is, of course, a hoped-for end in itself, but
higher rates of child survival are also a precursor to the demographic
transition toward lower fertility rates, which in turn improves quality of
life and spurs development.
Health
The importance of safe drinking water and basic sanitation to the preservation
of human health, particularly among children, cannot be overstated. Waterrelated diseases are the most common cause of illness and death among the
poor of developing countries. According to the World Health Organization,
1.6 million deaths per year can be attributed to unsafe water, poor sanitation, and lack of hygiene (WHO 2004a). Realizing the health-related Goals,
particularly those targeting child mortality and major diseases, will require a
dramatic increase in access to safe drinking water and basic sanitation services
for poor women, men, and children in developing countries. It will also require
20
Part 1
changes in behavior and attitudes, particularly with regard to hygiene, a critical but often overlooked element in discussions usually dominated by questions of access and service provision (box 2.3).
The health impact of poor quality water supply and sanitation services
and water-related diseases on developing countries is devastating (UN/WWAP
2003; WHO 2004a):
At any given time, close to half the people in the developing world are
suffering from one or more of the main diseases associated with inadequate provision of water supply and sanitation services: diarrhea, ascaris, dracunculiasis (guinea worm), hookworm, schistosomiasis (bilharzias, or snail fever), and trachoma.
More than half the hospital beds in the world are lled with people suffering from water-related diseases.
Billions of cases of diarrhea each year cause 1.6 million deaths, the vast
majority among children under ve, mostly in developing countries.
88 percent of diarrheal disease is attributed to unsafe water supply or
Box 2.3
Maximizing the
health benets
from water
supply, sanitation,
and hygiene
interventions
Source: Ghosh 2004.
Experience suggests that, to maximize the health benets from water supply, sanitation,
and hygiene interventions, it is critical to:
Think about health from the start
A common difculty in multidisciplinary activities is that experts from one sector often
develop most of the project, only involving experts from other sectors after fundamental
decisions about the level of service and the types of intervention have already been made.
If health benets are a project aim, then public health specialists should be involved from
the outset.
Focus on quantity as well as quality of water supply
Schemes that increase the number of public taps in either rural or urban settings, but
do not signicantly change the time required to fetch water will not increase household
water consumption, regardless of how much water is available at the tap. Such interventions thus cannot be expected to reduce water-washed transmission of disease, and
therefore can claim relatively few direct health benets. By contrast, schemes that permit
more household connections or reduce long travel times to less than half an hour can be
expected to lead to increased water use and a resulting reduction in disease.
Focus on changes at the household level
Programs intended to improve environmental health must be driven by the impact they
have at the household level. This is where most people (especially children) spend most of
their time and are most vulnerable to contamination. Unless improvements can be shown
to have an impact at the household level, they are unlikely to improve health.
Seek improved health indicators, rather than improved health statistics
Health impacts from water supply and sanitation interventions are notoriously difcult to
assess. There are too many random variables to gain reliable information from statisticsbased surveys. Better results come from observing practical outcomes, such as the use and
maintenance status of facilities or improvements in hygiene practice, such as hand washing.
Chapter 2
Billions of
cases of
diarrhea each
year cause
1.6 million
deaths, the
vast majority
among
children
under ve
21
inadequate sanitation and hygiene. Improved water supply reduces

diarrhea morbidity by 21 percent; improved sanitation reduces diarrhea morbidity by 37.5 percent; and the simple act of washing hands at
critical times can reduce the number of diarrheal cases by as much as
35 percent. Additional improvement of drinking-water quality, such as
point-of-use disinfection, would lead to a reduction of diarrhea episodes
of 45 percent.
Though not well documented, the trauma of watching a much loved
young child die from a preventable, water-related disease, such as diarrhea, as do one in ve in the poorest pockets of the world, no doubt has
serious and lasting impacts on the psychological and emotional health
of surviving parents and siblings.
Some 6 million people worldwide are blind because of trachoma, and
more than 150 million people are in need of treatment. It is the leading
cause of preventable blindness. The disease is strongly related to overcrowding and the absence of nearby sources of safe water for washing
the face and hands. Improving access to safe water sources and better
hygiene practices can reduce trachoma morbidity by 27 percent.
Intestinal helminths (ascariasis, trichuriasis, hookworm disease) affect
hundreds of millions of people; 133 million suffer from high-intensity
intestinal helminth infections, which often lead to severe consequences,
such as cognitive impairment, massive dysentery, or anemia. These diseases cause around 9,400 deaths every year. Access to safe water supply
and basic sanitation facilities combined with better hygiene practice can
reduce morbidity from ascariasis by 29 percent. Overall, healthy peopleas opposed to those sickened by wormsare better able to derive
the maximum nutritional benets from food; much of the caloric intake
of people suffering from worms is captured by the parasites.
Worldwide, an estimated 160 million people are infected with schistosomiasis. The disease causes tens of thousands of deaths every year,
mainly in Sub-Saharan Africa. It is strongly related to unsanitary excreta
disposal and absence of nearby sources of safe water. Basic sanitation
reduces the disease by up to 77 percent.
Arsenic in drinking water is a major public health threat. In Bangladesh, between 28 million and 35 million people consume drinking
water with elevated levels of arsenic; the number of cases of skin lesions
related to arsenic in drinking water is estimated at 1.5 million. Arsenic contamination of ground water has been found in many countries,
including Argentina, Chile, China, India, Mexico, Thailand, and the
United States.
More than 26 million people in China suffer from dental uorosis due to
elevated uoride in their drinking water, and more than 1 million cases
of skeletal uorosis are thought to be attributable to drinking water.
22
Part 1
The vicious
circle of
poverty and
ill-health
is endemic
among the
poorest
Cholera epidemics are a major risk where there are large concentrations
of people and hygiene is poor (as in refugee camps and urban slums);
an epidemic that began in Peru in 1990 spread to 16 other countries in
Latin America, and ten years later cholera remains endemic following
its absence from the continent for nearly a century.
Water containers typically hold 20 liters of water and weigh 20 kilograms. Carrying such heavy loads, commonly on the head or back, for
long distances each day, can result in headaches, fatigue, and pain or
even serious injury to the head, neck, spine, and pelvis. Women are
responsible for carrying water, and spinal and pelvic injuries can cause
problems during pregnancy and childbirth; reducing water portage burdens can reduce maternal mortality risks. Children who carry water can
also suffer serious and lasting injury.
Improved health overall from clean water, sanitation, and better nutrition reduces susceptibility to anemia and other conditions that affect
maternal mortality.
The vicious circle of poverty and ill-health is endemic among the poorest:
poverty renders women and men ill-equipped to protect themselves and their
children from biological pathogens and chemical hazards or to seek treatment
for illness; and their poor health, impaired ability to work, and high health
costs further mire them in poverty.
Adequate water supply and sanitation, coupled with hygienic behaviors
(especially hand washing, safe water handling and storage, and the safe disposal of feces) are fundamental to health because the main culprit in the transmission of water-related disease is the fecal-oral cycle. Water and sanitation
practitioners have a mnemonic device to describe the factors that fuel this
destructive cyclethey refer to the Five Fs (UNDP 2004):
Fluid (drinking contaminated water and having too little water to wash).
Drinking contaminated water transmits waterborne fecal-oral diseases
such as cholera, typhoid, diarrhea, viral hepatitis A, dysentery, and dracunculiasis (guinea worm disease). Insufcient quantities of water for
washing and personal hygiene lead to water-washed disease; when people cannot keep their hands, bodies, and domestic environments clean,
bacteria and parasites thrive, causing skin and eye infections, including
trachoma, and fecal-oral diseases are more easily spread.
Feces (the contamination of water, soil, and food with human fecal matter). Sanitation facilities interrupt the transmission of much fecal-oral
disease by preventing human fecal contamination of water and soil. It
is particularly important in controlling worm infections. Because children are the main victims of diarrheal diseases (which can be either
waterborne or water-washed), they are also the mostly likely source of
infection; the safe disposal of childrens feces is thus critical. To balance
Chapter 2
Traditional
roles and
tasks mean
that poor
women are
hit hardest by
inadequate
services
23
human as well as environmental health, fecal matter should be treated

as close to the point of defecation as possible.
Fingers (unwashed hands preparing food or going into the mouth). Recent
research shows that hand washing does more for reducing child mortality
and the incidence of infectious intestinal diseases than the provision of
safe water or even latrines. Yet hygiene gets surprisingly little focus.
Food (eating contaminated food). Eating contaminated food presents
the same health risks as drinking contaminated water, and careful food
handling is key to combating gastrointestinal illnesses.
Flies (spreading disease from feces to food and water or directly to people).
Flies are particularly problematic where open-air defecation is the norm.
Breaking the oral-fecal cycle depends upon the adoption of healthful practices (such as hand washing) and use of technologies that contain and sanitize
fecal matter. Addressing water and sanitation problems in developing countries
is critical to reducing morbidity and mortality. Health is often viewed from a
curative perspective; it is easy to forget how effective and affordable preventative approaches can be. Improving the quantity and quality of water that
households receive, improving the management of human excreta, and promoting hygienic practices, such as hand washing and safe water storage in the
home, are arguably the most effective health interventions that can be made in
the worlds poorest countries (boxes 2.4 and 2.5). For children in particular,
improving access to water supply and sanitation is one of the most effective
ways of improving health and quality of life.
Gender equality
The iconic image of a woman carrying water on her head is emblematic of a
lifelong burden that keeps girls from attending school, prevents women from
engaging in productive work, and fetters progress toward the Millennium
Development Goals on universal primary education and gender equality.
Throughout the developing world, in urban as well as rural areas, the gender division of labor typically assigns to women a series of roles and responsibilities that, for the most part, men do not share. They include securing water for
household needs such as drinking and washing; cooking and ensuring overall
household food security; and caring for children, the elderly, and the ill.
These traditional roles and tasks mean that poor women are hit hardest by
the inadequate services available in informal urban settlements. It is they who
must spend much of the day waiting in line for water, thus forestalling their
ability to engage in productive activities, adult education, or other domestic
responsibilities, not to mention rest and recreation. They are in greatest physical contact with contaminated water and human waste, exposing them to a
host of biological pathogens and chemical hazards, and are saddled with the
unenviable task of nding a way to dispose of the familys wastewater and
feces (no small challenge in areas where diarrheal diseases are endemic and
24
Part 1
Box 2.4
Where does
hygiene t in?
Source: WHO 2004a;
WSSCC website.
Box 2.5
Household water
treatment and
safe storage
Source: WHO International
Network to Promote
Household Water
Treatment and Safe
Storage (www.who.
int/household_water).
Hardware alone cannot improve health very much: What matters is the way in which it is
used and the extent to which it is accompanied by efforts to promote changes in hygienerelated behavior. In some cases, this change is fairly automatic; people across the world
need little encouragement to increase the amount of water they use for washing once it is
readily available at the household level. In other cases, however, a signicant amount of
time and effort is required to alter hazardous practices that are wrongly considered safe
or are simply not thought about.
Even after substantial investments have been made in water supply and sanitation
hardware, hygiene behavior in these areas often remains a substantial risk to health. In
many cultures, for example, the excreta of young children are considered safe and are
thus not treated with the same hygienic concern as the excreta of adults. In fact, children
are a signicant reservoir of infection. This means that the feces of children can be just as
infectious as those of adults. The practice of washing hands with soap after defecation is
another example of a behavior that does not follow automatically from the provision of
hardware, and yet has major health implications.
According to the World Health Organization, improved water supply reduces diarrhea
morbidity by 21 percent; but the simple act of washing hands at critical times can reduce
the number of diarrheal cases by up to 35 percent, and additional improvements of drinking-water quality, such as point-of-use disinfection and safe storage, would lead to a
reduction of diarrhea episodes of 45 percent. According to the Water Supply and Sanitation Collaborative Council, safe disposal of childrens feces leads to a reduction of diarrheal disease of nearly 40 percent.
Helping households improve and maintain water quality at home has proven health benets, is cost-effective, and contributes directly to meeting the Millenniuim Development
Goals. Household water treatment and safe storage can serve as an immediate mechanism to reduce illness among the unserved. A recent study conducted among 400 households in a Malawian refugee camp indicated that point-of-use interventions resulted in 31
percent fewer cases of diarrheal disease in children under ve. Moreover, other recent
evidence demonstrates that household water treatment reduces diarrheal disease at levels comparable to sanitation and hygiene measures.
Promising treatment technologies include chlorination, combined chlorination and occulation, solar disinfection, and ltration. Treatment needs to be accompanied by safe
storage, which can be accomplished by using a container with a narrow opening and a
dispensing device such as a tap or spigot to protect collected water. These measures
are particularly important because the bacteriological quality of drinking water frequently
declines after collection.
Although there are challenges, particularly with regard to achieving widespread adoption and sustainability of the interventions, household water treatment offers a rapid and
affordable way of reducing the global burden of waterborne disease.
sanitation facilities nonexistent). Having no safe, private sanitation facilities in

areas where people are living cheek-by-jowl means going the whole day without
Chapter 2
The gender
division of
labor means
that the
impact of
resource
degradation
is felt most
keenly by
women
and girls
Box 2.6
How long are
we going to live
this way?
25
relieving oneself and then risking exposure at nighta humiliating, stressful,

and uncomfortable daily routine that can damage health (box 2.6).
In rural areas, the gender division of labor means that the impact of resource
degradation is felt most keenly by women and girls, who must walk further
distances to fetch water, often of poor quality. In some countries, spending six
hours per day collecting water to meet the familys needs is not unusual. In
rural Africa, for instance, women commonly walk 10 kilometers each day to
the nearest water source to fetch water for their household needs, often twice
that during the dry season (WaterAid website). The need to travel further from
home to secure the familys water can expose women and girls to sexual harassment and rape; this can also happen when women who lack safe, nearby sanitation facilities move about at night in search of privacy. Women often combine
their water-carrying tasks with other domestic responsibilities, such as gathering fuel or food, but even when that is the case, the burdens of water portage
remain many, serious, and disproportionately borne by women.
For both rural and urban women, caring for children and other family
members who fall ill with water-related illnesses, an all-too-frequent occurrence, falls on their shoulders as well. Higher rates of child survival are a precursor to the demographic transition toward lower fertility rates, and having
fewer children reduces womens domestic responsibilities as well as their maternal mortality and morbidity risks.
The impact of poor water supply and sanitation services on poor womens physical security, opportunities for adult education, overall productivity,
income-generating capacity, nutritional status, time, and overall health and
well-being is severe. The accumulation of these negative impacts starts in girlhood. Girls rather than boys generally help their mothers collect water, and
in some parts of the world this task becomes a girls responsibility when she is
nine or ten. Collecting water is physically taxing as well as time-consuming,
There is no water to wash our hands when we use the nearby bushes, plastic bags, or the
only public toilet available some distance from our homes. There is always ghting on who
will be next although there is a queue. Everyone watches. There are no doors for privacy.
How long are we going to live this way? It is affecting our pride and dignity.
Sometimes we have to go to the back of our house to defecate in a plastic bag and
throw it in nearby bushes or in the gullythis is called kitting. The problem gets worse
during menstruation both for us and our daughtersthey too cant attend school as there
is nowhere at school for them to clean themselves, and we the mothers dont have enough
water to wash our bodies and to feel clean.
We dont want our children to continue growing up this wayit is too distressing.
Life like this will make it hard for our children to t into society. My daughter would like to
be a classy lady one dayshe would love to marry someone who has their own sanitary
convenience in their homes.
Charlene, age 42, Caribbean urban slum.
26
Part 1
The lack of
adequate
sanitation
facilities
also prevents
girls from
attending
school
Box 2.7
Modest dreams
and when water is scarce or far from home, girls need to spend more time on
this task, reducing their time in school.
The lack of adequate sanitation facilities also prevents girls from attending
school, particularly when they are menstruating. Many parents simply will not
allow their daughters to attend schools that do not have separate sanitation
facilities for boys and girls after menarcheand few schools in poor areas do.
The Millennium Project Education Task Force has concluded that schooling
does not provide signicant benets until a minimum threshold of competencies is reached; the greatest gains to girls, their future children, and their societies come when girls are able to complete secondary school. If girls schooling
comes to an end as they enter adolescence, this minimum threshold cannot
be reached. Studies show that girls attendance at school is increased through
improved sanitation. For example, in Bangladesh a school sanitation program
has increased the enrollment of girls by 11 percent every year since it began in
1990 (WaterAid website).
The disparities in girls and boys ability to attend school have lifelong
impacts, for women as well as for their future families and communities (box
2.7). This is why the Millennium Development targets related to womens
empowerment track educational attainment from the primary grades upward.
Even women who have had just a few years of basic education have smaller,
healthier families, are more likely to be literate, and are more likely to view
educating their own children as a priority, even if income is held constant.
According to the U.K. Department for International Development, each additional year of female education reduces childhood mortality by 510 percent
(WaterAid website).
Thus, the Millennium Development Goals for water and gender interact
in several ways:
Women and girls are most seriously affected by inadequate water supply
and sanitation services, as described above.
Community action and social mobilization around the provision of
such basic social services as water have been shown to be a valuable
entry point for promoting womens empowerment. Having a leadership
role in community management of water supplies, for instance, can
At least my daughters education will ensure that she will get a groom who comes from
a home with a toilet.
Manjulaben, age 38, a daily wage laborer from
Nagalpur village, Gujarat state, India.
I do wish that I get married in a family which has the facility of toilet and separate water
tap. It is a dream for me.
Barkha, age 12, Sanjay Amar Colony, Delhi, India.
Chapter 2
The
disparities
in girls and
boys ability
to attend
school have
lifelong
impacts
27
increase womens social capital as well as their bargaining power within

the household.
Because of differences in production, labor, responsibilities, and
resources, women and men have different interests in and derive different benets from the availability, use, and management of water.
Women, for instance, generally prioritize water for such domestic uses
as drinking and washing, whereas men may focus on irrigation. As a
result, they often have different criteria to evaluate the adequacy, equity,
timeliness, convenience, and quality of various interventions. Furthermore, women and men often have different perceptions about the costs
and benets related to participation in the various types of water users
groups through which water use and management are organized. In
addition, they differ in their ability to participate in such schemes.
Young women may simply not be able to participate in community
management efforts if they have small children to care for; if meetings
are held at night, safety concerns or cultural norms may keep them
home. All these factors can be discovered and addressed by taking a
gender-sensitive approach.
Chapter 3
Target 10 and the global

monitoring system
Monitoring progress on the Millennium Development target for water and

sanitation requires a common agreement on three issues: the terminology for
access to both water and sanitation, the operational meaning of the agreed
terminologies, and survey instruments and indicators for assessing progress
toward halving, by 2015, the proportion of people without sustainable access
to safe drinking water and basic sanitation.
The target for safe drinking water was dened at the Millennium Summit, as part of the Millennium Development Goals, although the summit did
not specically dene the terms safe or sustainable access. The baseline global
data available on the current status of this target are contained in the midterm assessment of progress prepared by the WHO/UNICEF Joint Monitoring Programme, or JMP (WHO/UNICEF JMP 2004). Whereas the Millennium Development target on water uses the term safe drinking water, the JMP
report refers to access to improved water technology. It has been argued that
this change in terminology reects both the past misrepresentation, and the
future uncertainty, in judging and dening services as safe in terms of human
health (Hunt 2001).
It is very difcult to measure global coverage of safe water or sanitary excreta
disposal routinely, because monitoring aspects of service, such as the quality of
water at the point of consumption or the correct usage of sanitary facilities, is
not currently within the scope of national surveys or other data sources. Surveys
typically register the presence or use of water supply and sanitation facilities of
different technology types. The JMP report assumed that those technologies
that can be categorized as improved are inherently safer or more sanitary than
others that are considered not improved. Therefore, the coverage estimates from
JMP are expressed as the percentage of population with access to improved
drinking water sources and improved sanitation, as dened in table 3.1.
Chapter 3
Target 10 and the global monitoring system
Table 3.1
Improved and
unimproved water and
sanitation facilities
Water supply
a. Not considered improved

because of potential limits on
the quantity of water available to
a household through this source,
not the quality of the water.
Source: WHO/UNICEF Joint
Monitoring Programme.
Sanitation
29
Improved
Unimproved
Piped connection into

dwelling, plot, or yard
Unprotected well
Public tap or standpipe
Unprotected spring
Borehole
Vendor-provided water
Protected dug well
Bottled watera
Protected spring
Tanker truckprovided water
Rainwater
River, stream, pond, or lake
Connection to public
sewer or septic tank
Service or bucket latrine
Pour-ush latrine
Traditional latrine
Pit latrine with slab
Public latrine or shared toilet
VIP latrine
Open pit or pit latrine without a slab
Ecological sanitation
Open defecation in bush or eld
It appears, however, that the meaning of improved is still an issue. One

interpretation has been proposed by a task force on monitoring established by
the Water Supply and Sanitation Collaborative Council (WSSCC). According
to the WSSCC task force, a person is said to have access to improved water supply if the person has access to sufcient drinking water of acceptable quality as
well as sufcient quantity of water for hygienic purposes.1
As mentioned earlier, the target for sanitation was established at the 2002
World Summit on Sustainable Development (WSSD) and subsequently incorporated into the list of Millennium Development targets. The terminology chosen
for this target is basic sanitation. In contrast, the terminology used in the JMP
report is improved sanitation, which is dened in the JMP report as a sanitation
system in which excreta are disposed of in such a way that they reduce the risk of
fecal-oral transmission to its users and the environment. The WSSD denition of
basic sanitation is broader; it links access to sanitation to improved human health
and reduced infant and childhood mortality. The WSSD denition included:
Development and implementation of efcient household sanitation
systems.
Improvement of sanitation in public institutions, especially in schools.
Promotion of safe hygiene practices.
Promotion of education and outreach focused on children, as agents of
behavioral change.
Promotion of affordable and socially and culturally acceptable technologies and practices.
Development of innovative nancing and partnership mechanisms.
Integration of sanitation into water resources management strategies in a
manner that does not negatively affect the environment (that is, it includes
protection of water resources from biological or fecal contamination).
The WSSD denition is broader than what is envisaged in the JMP report
and is more impact-oriented, particularly in communities that currently have
30
Part 1
Issues of
privacy
and dignity
are also
important
very low levels of sanitation service. The WSSD is also not focused on the construction of a particular number of toilets as the target goal, but rather on the creation of an overarching process for improved health and hygiene through basic
sanitation. The JMP is also concerned with this broader goal, but has been constrained by the need to ensure that its denition of and indicators for improved
sanitation can be monitored using existing household survey instruments. The
JMP also needs to ensure comparability of data across time and countries. Nonetheless, the JMPs emphasis on the use of particular household technologies
ignores health risks associated with poor disposal of sullage2 or wastewater from
domestic sources (for example, risks such as lariasis and schistosomiasis). Moreover, issues of privacy and dignity are also important components of monitoring
in sanitation, as they inuence willingness to use sanitation facilities regularly
(box 3.1).
With these considerations in mind, the task force denes basic sanitation as:
the lowest-cost option for securing sustainable access to safe, hygienic,
and convenient facilities and services for excreta and sullage disposal
that provide privacy and dignity, while at the same time ensuring a
clean and healthful living environment both at home and in the
neighborhood of users.
This denition implies that technology for basic sanitation is not a contextfree system, but rather a situation-determined, lowest-cost technology appropriate for the physical, environmental, and nancial resources of both the supply
side and the demand side of access. The specic technologies that meet these
conditions may differ from place to place: in dispersed, low-income rural areas,
the appropriate technology may be a simple pit latrine; in a congested urban
slum area with reliable water service, it may be a low-cost sewerage system.
Box 3.1
What is
sanitation?
Most professionals agree that sanitation as a whole is a big idea that covers, among
other things:
Safe collection, storage, treatment, and disposal, reuse, or recycling of human
excreta (feces and urine).
Drainage and disposal, re-use, or recycling of household wastewater (often referred
to as sullage or grey water).
Management, reuse, and recycling of solid wastes (trash or rubbish).
Drainage of stormwater.
Treatment and disposal, reuse, or recycling of sewage efuents.
Collection and management of industrial waste products.
Management of hazardous wastes (including hospital wastes and chemical, radioactive, and other dangerous substances).
Target 10 refers primarily to the rst and second items on this list. It focuses on the
collection, treatment, and disposal of human excreta and the drainage and disposal of
household wastewater (sullage).
Chapter 3
There is a
need to strike
a workable
balance
between what
is desirable
to measure
and what is
possible
31
With basic sanitation, access at the household level should be sufcient. Yet
the goals of such access include broader impacts on public health and environmental pollution. Hence, at the very minimum, the denition of access should
reect a healthful environment at the neighborhood level. While household
solutions may be sufcient in a rural environment or in a dispersed settlement,
they would be woefully inadequate in an urban area, especially in urban slum
areas or in congested urban areas and megacities. For such situations, we would
need to go beyond access at the household level to provide proper collection
systems, such as an appropriate form of sewerage, together with facilities for
treatment and disposal of the collected sewage.
In dening indicators that will be used as the basis for monitoring, it is
necessary to strike a balance between ideal but often impracticable indicators
completely consistent with conceptual denitions and measurable indicators
that can act as proxies for the denitions. It is such measurable indicators that
should form the basis for developing the main monitoring instruments at the
national and international levels. For instance, from a gender perspective, the
denition of improved water supply would ideally include some measure of
the distance between a household and its water source, as the distance women
must travel for water has many impacts on their lives, from the amount of time
they must spend on water gathering to questions of physical safety. Similarly,
having separate sanitation facilities for men and women and, at schools, for
girls and boys, as well as the physical location of such facilities, also affects
regularity of use, womens physical safety, and girls school attendance. Disaggregating service access data by gender would also yield important information, allowing for assessment of the degree to which both men and women are
beneting from interventions in this area.
However, if the information collected from, for instance, household surveysamong the most reliable methodsdoes not track access by gender, distance to water sources, or the presence of separate sanitation facilities for men
and women, then creating monitoring indicators based on these considerations
presents a host of operational difculties. There is a need to strike a workable
balance between what is desirable to measure and what is possible to measure,
and cost is an important variable in this exercise.
At the start, it is important to highlight four issues inherent in target 10:

First, the baseline date for these targets, which was not explicit in the
original wording, needs to be claried. Several other Millennium Development targets (1, 2, 5, 6, and 11) call for specic improvements with respect
to some baseline year, but with the exception of target 11 on slum dwellers,
they all specify this baseline year as 1990. Moreover, in the case of target 11,
this ambiguity matters slightly less, since an absolute number of slum dwellers
whose lives are to be improved is arguably an inappropriate way to measure
32
Part 1
Sustainable
access must
be viewed
from social,
economic, and
environmental
perspectives
progress at the country level. This task force, therefore, needed to make its own
determination of the baseline date. Taking into account that the UN Statistics
Division and UNICEF use 1990 as their baseline year and that, as a result, the
UN secretary-generals report on progress toward achieving the Millennium
Development Goals will use the same year, the task force adopted 1990 as the
baseline date, to ensure maximum consistency with other UN publications
and the work of the secretary-general.
Second, sustainable access must be viewed from social, economic, and
environmental perspectives. Access includes a physical dimensionfor example, access to drinking water requires the existence of infrastructure in good
working orderbut also embraces a concept of use.3 Access to sanitation, for
example, cannot be measured simply by whether a toilet is installed, but must
also determine whether that toilet is working and used for safe disposal of
excreta with improved hygienic practices. Otherwise, the contribution of the
toilet itself to human health will be negligible or even negative.
There are likewise two aspects of sustainability, a service aspect and an
environmental aspect. In terms of service, sustainable access refers primarily
to a type of service that is secure, reliable, and available for use on demand by
users on a long-term basis. This is possible when there are credible arrangements to ensure a regular and reliable ow of adequate performance-determining resourceshuman, nancial, institutional, and technical know-how,
among othersneeded to ensure proper functioning and satisfactory operation and maintenance of service infrastructure.
In terms of environmental impact, sustainable access refers to the effects on
resources within or outside the service area of the technology and the processes
required for adequate access. Thus, such technology and processes should not
result in environmental damage or other negative consequences within or outside the service areas, such as exposing people to health risks or creating pollution or degradation of the local living environment or of downstream water
resources. In a broader sense, the service should also be one that meets the
needs of the present [generation] without compromising the ability of future
generations to meet their own needs (World Commission on Environment
and Development 1987); it should be one that does not compromise the goals
of sustainable development, namely, economic development, social equity and
justice, and environmental protection.
Third, the targets can and should be set (and monitored) at both global
and national levelsand even subnational levels for large nations such as
Brazil, China, India, and Nigeria. National targets must be owned by each
countrysome countries, for example, are well on track to achieving one or
more of the above targets and can aspire to something much more ambitious
than the Millennium Development targets, which are minimum targets for
all countries. Likewise, intermediate milestones (for 2005 and 2010) should
be set at both national and global levels (as well as subnational levels, where
Chapter 3
The targets
should be
set (and
monitored) at
both global
and national
levels
and even
subnational
levels
Figure 3.1
Millennium
Development Goals for
water and sanitation
reach the neediest in
urban and rural areas
33
appropriate). Progress at all levels should be monitored and evaluated in terms

of these intermediate milestones.
Fourth, the target itself has four components, as depicted in greater detail
in gure 3.1.
The current system for monitoring and evaluation
In 1990, at the end of the Water and Sanitation Decade, the World Health
Organization (WHO) and the United Nations Childrens Fund (UNICEF)
joined their efforts in monitoring the water supply and sanitation sector through
the WHO/UNICEF Joint Monitoring Programme for Water Supply and Sanitation.4 The purpose of the JMP was to:
Monitor sector progress toward internationally established goals on
access to water supply and sanitation.
Monitor sector trends and programs.
Build national sector monitoring capacity.
Inform national and global policymakers on the status of the sector.
Over the past decade, the JMP focused on monitoring access coverage at
the global and regional levels. To that end, the JMP compiled coverage rates
on water supply and sanitation using information provided primarily by water
utilities and government sources. JMP sector assessment reports based on this
methodology were issued in 1991, 1993, and 1996.
The latest JMP report, a midterm assessment of progress on meeting the
water and sanitation target (WHO/UNICEF JMP 2004), provides a comprehensive review of the water supply and sanitation sector in 2002, which represents the halfway point between the target year of 2015 and the baseline year of
1990. It presents country-by-country coverage data, global and regional data,
trends over the period 19902002, an examination of disparities in access, and
projections to 2015.
The coverage estimates5 provided in the JMP2004 come from user-based
data derived from nationally representative household surveys6 and censuses.
This important shift in methodology away from using provider-based data in
favor of evidence-based data began with the last JMP report in 2000. This
34
Part 1
The current
major survey
instruments
ask only a
few questions
about
domestic
water supply
and sanitation
shift was made possible after the introduction of the Multiple Indicator Cluster
Surveys (MICS) by UNICEF in 64 countries in 1995, and the MICS2 around
2000 in 67 countries. With these 131 MICS results, in addition to more than
150 Demographic and Health Surveys, or DHS surveys (which are funded by
USAID and conducted by ORC-Macro) and data from national censuses now
available, there is a large enough database to calculate coverage estimates using
evidence-based data.
Why are the data derived from household surveys better than those supplied by governments and water utilities? In many cases, provider-supplied estimates are based on facilities constructed under their programs multiplied by an
estimated number of users per facility. This means that facilities constructed
by households themselves, nongovernmental organizations, or the private sector might not have been included. It also means that systems that have broken
down or for other reasons are not being used might be counted. Urban and
periurban slums, even those that are home to hundreds of thousands of people,
are sometimes not counted in ofcial government reports because of questions
of tenure; access in such areas tends to be very poor, and when the people living there are not counted, a signicant over-reporting of coverage can result.
In addition, political, institutional, career, and other pressures can sometimes
create incentives for suppliers to inate the number of people reported to have
access. Therefore, household-level information gathered through household
surveys gives a better reection of the real situation on the ground.
In response to monitoring the World Summit for Children goals, UNICEF greatly expanded its monitoring capacity. Through its country ofces,
UNICEF currently has a reporting system in place that tracks all surveys with
relevance for child protection, survival, and development that are conducted at
the national level (in addition to DHS and MICS, the scope includes health
and nutrition surveys, reproductive health surveys, living standard measurement surveys, and the Gulf Family Health Survey, among others). When survey
results are ofcially produced, copies are sent to UNICEF headquarters, where
the survey methodology and design are assessed and relevant data extracted.
UNICEF and ORC-Macro, responsible for the DHS surveys, have been
coordinating their surveys for some years now. Yearly household surveys are
likely to show change within the margin of error of the previous survey results.
To avoid this, DHS and MICS aim to have at least three years between surveys. Thus, if a MICS survey has been conducted in 2001, a DHS survey will
not be conducted in the same country until 2004 or later. This strategy maximizes the scarce resources and limits survey fatigue among households, which
is a possible confounding factor. UNICEF and ORC-Macro also cooperate in
harmonization of survey questions and indicators.
The current JMP database contains water supply and sanitation coverage
data from more than 350 national household surveys and censuses conducted
throughout the developing world in the past 15 years. The widely used gures
Chapter 3
No questions
are asked
about
reliability,
affordability,
or distance
35
of 1.1 billion people without access to drinking water and 2.6 billion without
access to sanitation are derived from this JMP database.
Limitations of household surveys
The current major survey instruments ask only a few questions about domestic
water supply and sanitation. They focus on questions of use like these:
What is the main source of drinking water for members of your
household?
How long does it take to go there, get water, and come back?
What kind of toilet facility does your household use?
No questions are asked about the reliability of the water supply, the quality
or affordability of water, the distance between the household and the water or
sanitation facility, or the availability of separate sanitary facilities for women
and men. Nor do the surveys assess how hygienic a sanitary facility really is.
Both the DHS and MICS surveys strive to strike a balance between the
desirability of obtaining information and the burden imposed by the time
needed to conduct a survey interview. Cost is an issue. A regular MICS or
DHS interview takes between 45 minutes to one hour to complete. The MICS
surveys are usually conducted in 4,0006,000 households, and the DHS in
6,0009,000 households (UNICEF MICS website; Macro International DHS
website). Limiting the number of survey questions to those that have relevance
for global-level monitoring is therefore of utmost importance.
Although the current ve to seven questions on water and sanitation in the
MICS and DHS may be expanded to include a few additional indicators with
global relevance, it is likely that the demands of the sector require additional information. Current demands include information on hygiene and hygiene behavior
(hand washing) and disaggregation of data for periurban areas or subnational levels. Mapping of the current survey instruments in geographic information systems
(GIS) is still insufcient, as the current DHS and MICS survey designs stratify
their sampling for an entire country and not for separate regions. Regional stratication, as is done in a very large country such as India, could easily increase the
sample size vefold to tenfold to 60,000 households. Such surveys therefore are
better done at the individual country level targeting specic regions of interest
the benets of global monitoring of subregional coverage most likely do not outweigh the costs. Rapid appraisal techniques are probably a good and cost-effective
alternative to household surveys to assess particular water, sanitation, and hygiene
problems in specic subregions. The unofcial standard applied to the MICS for
inclusion of a survey question is whether that question or indicator has relevance
for measuring progress toward an internationally established global goal.
The JMP Advisory Group
The JMP broadened its participation base beyond WHO and UNICEF with
the establishment of a JMP Advisory Group in 2003. This advisory group is
36
Part 1
Close
cooperation
with other
international
organizations
will surely
benet the
process
made up of leading eld and academic experts in water supply, sanitation and
hygiene, sector monitoring, and data collection.7 Its main role is to advise the
JMP secretariat about how to improve its work and expand its scope beyond
monitoring of access. Members of the advisory group include representatives
from the following institutions:
London School of Hygiene and Tropical Medicine.
Water and Environment Development Centre (WEDC), Loughborough University, U.K.
Water Supply and Sanitation Collaborative Council (WSSCC).
Environmental Health Project (EHP).
The Water Supply and Sanitation Programme of the World Bank.
The African Water Association.
ORC-Macro, which is responsible for carrying out DHS surveys
worldwide.
Recommendations from the rst advisory group include enhancing the
quality and quantity of data through:
The promotion of harmonized survey questions and indicators among
the main survey instruments and at individual country level.
The inclusion of additional indicators, specically on hygiene and
hygiene behavior with relevance for global monitoring.
Promotion of the JMP methodology and recognition and use of JMP
gures at the country level.
The advisory group also expressed the need for a higher reporting frequency by the JMP of its updated coverage estimates. From the trend lines
based on household survey data, the JMP can now produce yearly coverage
estimates through extrapolation of the trend (WHO/UNICEF JMP 2004
contains such estimates). In addition, the advisory group argued that the
JMP should better address the need for building national monitoring capacity and should investigate options for becoming involved in national sector
monitoring beyond monitoring of access.
In low-income countries, the JMP partners, WHO and UNICEF,
through their country representations and regional ofces, can play a proactive and supportive role in the preparation of such country assessment reports
and plans. Close cooperation with other international organizations, primarily the World Bank with its double role of technical advisor and nancer,
will surely benet the process. The added value of the JMP will be its experience in monitoring and reporting on global and regional trends within the
context of measuring progress toward the Millennium Development targets.
The national sector assessment reports and plans of action could serve as
advocacy tools for fundraising, as well as a roadmap for reaching the targets
on water supply and sanitation.
Chapter 3
National
sector
assessment
reports and
plans of
action could
serve as
advocacy
tools
37
JMP funding
Since its inception, the JMP has largely been funded from the regular resources
of the two lead agencies, UNICEF and WHO. The role of managing the JMP,
updating the country les with new survey data, producing regular reports on
coverage, and maintaining the JMPs presence in the sector at global forums
has on average received an input of between one and two person-years divided
over a total of six people within the two executing agencies. In other words, the
JMP has been operating on a shoestring. Costs for conducting the household
surveys and tracking and collecting all of the data have not been borne by the
JMP, but somehow should be taken into account to get an overall picture of
the costs of monitoring progress toward the Millennium Development Goals.
Although in the 1990s the JMP set out to ll an information gap, its scope has
expanded considerably under the UN secretary-generals mandate to monitor
progress toward achieving the targets on water and sanitation.
To ensure proper representation at global forums, to support a yearly
update of coverage estimates, and to promote the use of the JMP methodology
and data at the national level, it is estimated that at least three fulltime professional staff are needed. If the mandate of the JMP were further expanded into
national capacity building, including support to national sector assessments,
much more program funding would be required. An estimated operating budget of little more than $1 million a year would allow the JMP to carry out its
expanded role and to implement the recommendations of its advisory group.
This would include capacity-building efforts in 25 priority countries, making
use of the existing UNICEF and WHO infrastructure in each country. It also
includes a pilot project to test a rapid water quality assessment protocol developed by WHO, to be introduced for regular water quality surveillance, with
the potential to be run alongside a national-level household survey.
Chapter 4
Where are the needs greatest?
Any assessment of the chances of meeting the Millennium Development target

for water and sanitation must begin with three caveats. First is the need to distinguish between the target for water supply and that for sanitation. Although
both targets are mutually reinforcing and equally important, meeting the sanitation target is the far more daunting challenge for a variety of reasons, including lack of political will and commitment at the highest level, low effective
demand for sanitation among the unserved, inadequate nancing, the lack of
institutions at the national level responsible for sanitation, the relatively low
pay and status associated with work in the sanitation eld as opposed to work
in other sectors, and nearly universal cultural taboos surrounding discussion
(much less the handling) of human excreta. In addition, the scale of the problem is far greater for sanitation than for domestic water supply; more than
twice as many people (2.6 billion) lack access to sanitation than lack access to
water supply (1.1 billion) (WHO/UNICEF JMP 2000).
Second is the need to tailor strategies for water and sanitation to specic
circumstances at the regional, national, and subnational levels, and in rural
and urban contexts. To be effective, interventions, approaches, costing, and
nancing mechanisms must be highly context-specic. Action plans rooted
in generalities tend to be less effective than those that take advantage of local
opportunities and address local constraints.
Third is the need to recognize the limitations of available data for monitoring progress. Although the data sources used in this report are the best, most
reliable data sources available, they tend to understate the gaps in coverage.
Measuring access to domestic water supply and sanitation services is a tremendously challenging task that requires striking a balance between what is
conceptually desirable to measure and what is practical to measure.
Chapter 4
39
Given these caveats, how should policymakers, advocates, donors, and others
identify where the needs for intervention are greatest? The answer to this question is not as obvious as it might appear. It seems reasonable, for example, to simply identify areas where access to domestic water supply and sanitation services
is lowest. The United Nations has used this criterion, along with information on
progress toward the targets, to identify countries where existing coverage levels
are low and where the rate at which access to services is expanding is low or even
negative. Alternatively, areas where both access to services is poor and the incidence of water-related disease is high could be prioritized under the assumption
that investments should be allocated where their impacts on health are expected
to be the greatest. We consider each of these alternative approaches below.
Access to domestic water supply and sanitation services
The 2004 WHO/UNICEF Joint Monitoring Programme report (WHO/

UNICEF JMP 2004) describes regional coverage (map 4.1) for both improved
drinking water and improved sanitation in the baseline year of 1990 and in
2002, which is the halfway point for the 2015 targets. The JMP report, which
Map 4.1
Regional groupings for
the Joint Monitoring
Programme
Source: Joint Monitoring
Programme.
40
Part 1
is the most reliable source of global water supply and sanitation information,
indicates that Sub-Saharan Africa, Oceania, Eastern Asia, and Southeast Asia,
are the regions where coverage is lowest for both water supply and sanitation.
In 2002, about 1.1 billion of the worlds 6.2 billion people (18 percent)
lacked access to improved water supply, and about 2.6 billion people (42
percent) had no access to even the most basic forms of improved sanitation
(WHO/UNICEF JMP 2004). In the same year, drinking water coverage rates
were lowest in Oceania (52 percent) and in Sub-Saharan Africa (58 percent). In
absolute numbers, however, most of the 1.1 billion without access to improved
drinking water sources lived in Asia (61 percent), and 26 percent lived in SubSaharan Africa (table 4.1).
In 2002, sanitation coverage was lowest in Sub-Saharan Africa (36 percent)
and in South Asia (37 percent). As shown in table 4.2, most of those without
Table 4.1
Access to improved
drinking water sources
by region, 2002
Source: Adapted from
WHO/UNICEF JMP 2004.
Region
Sub-Saharan Africa
288
42
27
South Asia
234
16
22
Southeast Asia
115
21
11
60
11
Western Asia
23
12
Eurasia
20
Northern Africa
15
10
Developed economies
15
48
<1
1,076
na
100
Total
Table 4.2
Region
Number of people
in region lacking
access (millions)
22
Share of all unserved

living in indicated
region (percent)
303
Oceania
Source: Adapted from

Share of regional
population lacking
access (percent)
Eastern Asia
Latin America and Caribbean
Access to improved
sanitation by
region, 2002
Number of people
in region lacking
access (millions)
Share of regional
population lacking
access (percent)
28
Share of all unserved

living in indicated
region (percent)
South Asia
938
63
36
Eastern Asia
749
55
29
Sub-Saharan Africa
437
64
17
Southeast Asia
208
39
137
25
50
17
Eurasia
Northern Africa
40
27
Western Asia
38
21
Developed economies
20
45
<1
Oceania
Total
2,620
100
Chapter 4
In 2002,
about 1.1
billion of the
worlds 6.2
billion people
lacked access
to improved
water supply
41
access to improved sanitation lived in Asia (73 percent), while 17 percent lived
in sub-Saharan Africa. More than half of those without access to improved
sanitationnearly 1.5 billion peoplelive in just two countries, China and
India.
Based on these 2002 coverage levels, along with projected population gures from the United Nation Population Division, UNICEF has estimated
the number of people who must be reached with water supply and sanitation
facilities by 2015 in order to meet target 10 (table 4.3). For water supply, meeting the target requires that services be extended to 359 million more persons in
Sub-Saharan Africa, 444 million in South Asia, and 465 million in East Asia
and the Pacic. With regard to sanitation, the challenge in Sub-Saharan Africa
is of roughly the same scale as that for water supply; another 363 million persons must obtain access to sanitation by 2015 in order to meet the target. The
sanitation challenge is much more daunting in both South Asia and East Asia,
where services must reach more than 700 million in each region.
Current levels of access and the rate of progress toward the goal
The United Nations Human Development Reports for 2002 and 2003 provide
information on progress toward the Millennium Development target for safe
drinking water and sanitation, using JMP data for 2000 and 1990 as the baseline year (UNDP 2002, 2003). The 2002 assessment was undertaken for all
the United Nations member countries (except high-income OECD countries)
and included Hong Kong and China. For 75 countries, representing 10.3 percent of the worlds population, no assessment could be carried out because of
data unavailability.
The results of the Human Development Report analyses indicate that 25
countries have already achieved the Millennium Development target for water.
Of these, 4 (Singapore, Sri Lanka, Bangladesh,1 and Maldives) are from Asia;
only 1, Mauritius, is from Sub-Saharan Africa. Another 43 are considered to
be on track toward achieving the goal, of which 8 are from Asia and 9 are
from Africa. Finally, 25 countries are either lagging somewhat behind, considTable 4.3
Number of people to
whom access must
be extended by 2015
to meet target 10
Source: WHO/UNICEF JMP 2004.
Number of people to gain

access to improved water
supply (millions)
Region
Sub-Saharan Africa
Number of people to
gain access to improved
sanitation (millions)
Urban
Rural
Total
Urban
Rural
Total
175
184
359
178
185
363
Middle East and North Africa
104
30
134
105
34
140
South Asia
243
201
444
263
451
714
East Asia and Pacic
290
174
465
330
376
705
121
20
141
132
29
161
Former Soviet Union

and Baltic states
Total
27
27
24
24
961
609
1,570
1,032
1,076
2,108
42
Part 1
For several of
the poorest
countries
insufcient
data are
available
erably behind, or are even slipping in their progress toward the targets. Among
these, 13 are from Sub-Saharan Africa; only 4 (the Philippines, Viet Nam,
Myanmar, and China) are from Asia.
The Human Development Report 2003 assessment identies two groups
of countries that appear to need urgent changes of course in order to meet
the goals. In the rst group of countries, access to services is low and progress
toward the goal is stalled or reversing. The report argues that these countries
should receive the lions share of the worlds focus, resources, and assistance.
In the second group of countries, the situation is somewhat less desperate, but
the needs remain great. These countries either have medium coverage rates but
exhibit stalled or reversing progress, or have very low levels of coverage and are
progressing only very slowly. In addition, sufcient data are not available to
classify another 32 countries; if the data were better, no doubt at least some of
these would be included in these urgent needs categories.
In terms of access to water, the countries where access is poor and progress
toward the goal is stalled or reversing include ve in Africa (Ethiopia, Mauritania, Madagascar, Guinea, and Togo), one in East Asia and the Pacic (Papua
New Guinea), two in the Arab States (Oman and Libyan Arab Jamahiriya),
and one in Latin America and the Caribbean (Haiti). Countries with better prospects for meeting the goal but where challenges are still formidable
include eight in Africa (Uganda, Malawi, Cameroon, Niger, Nigeria, Namibia,
Cte dIvoire, and South Africa), two in East Asia and the Pacic (China and
the Philippines), and one in Latin America and the Caribbean (Trinidad and
Tobago). It is important to underscore that, for several of the poorest countries,
such as Sierra Leone and Burkina Faso, insufcient data are available. It is
likely that many such states would be included in this list.
In terms of access to sanitation, the countries where access to services is
poor and progress toward the goal is stalled or reversing include ten in Africa
(Ethiopia, Niger, Benin, Central African Republic, Mauritania, Madagascar,
Guinea, Togo, Nigeria, and Mali), two in the Arab States (Yemen and Sudan),
and two in Latin America and the Caribbean (Haiti and the Dominican Republic). Countries with better odds of meeting the goal but where challenges are
still substantial include nine in Africa (Chad, Namibia, Cte dIvoire, Zimbabwe, Botswana, Malawi, Cameroon, South Africa, and Burundi), three in
South Asia (India, Nepal, and Pakistan), three in East Asia and the Pacic
(China, Indonesia, and Papua New Guinea), and two in Latin America and
the Caribbean (Mexico and Brazil).
Low access to services and high incidence of water-related disease
A third perspective on identifying areas where the needs for accelerated action
in domestic water supply and sanitation are greatest focuses on the links
between water supply, sanitation, and health. It could be argued that resources
expended in locations that have both low levels of access to improved services
Chapter 4
43
and high prevalence of water-related diseases will be most likely to generate

substantial public health impacts.
Considering the intersection of access to water supply services and incidence of diarrhea, for example, leads to the identication of nine countries
in which coverage is less than 50 percent and diarrhea prevalence is between
20 percent and 40 percent of households (map 4.2). Of these, eight are in
AfricaAngola, Burkina Faso, Chad, Congo, Ethiopia, Eritrea, Guinea, and
Mauritaniaand one, Afghanistan, is in Asia. Indeed, with only one exception, those countries with the highest incidence of diarrhea are located in
Africa and Asia. It is notable, however, that several Latin American countries
with relatively high rates of coveragecountries that therefore do not emerge
as high-need areas in the analyses abovehave diarrhea prevalence rates of
1020 percent.
Map 4.2
Prevalence of diarrhea
and improved water
supplies, 2000
Source: Data from the United
Nations Childrens Fund and the
Joint Monitoring Programme.
Note: Data on prevalence of improved water supplies are for 2000. Data on prevalence of diarrhea are for various years,
19912000, and indicate prevalence in the two weeks before the survey. The prevalence of diarrhea may vary by season.
Because country surveys were administered at different times, data are not comparable across countries.
44
Part 1
The Millennium Development target for domestic water supply and sanitation
A similar analysis for sanitation services suggests that the number of countries in need of urgent action is greater; 15 nations have coverage rates below 50
percent and diarrhea prevalence between 20 percent and 40 percent (map 4.3).
As with water supply, all high-need countries identied with this approach are
in Africa and Asia. In Africa, these include Angola, Benin, Burkina Faso, Central African Republic, Chad, Congo, Ethiopia, Eritrea, Mauritania, Mozambique, Namibia, Niger, and Togo; in Asia, Afghanistan and Bangladesh.
Identifying greatest needs globally
Each of the three approaches to determining where water and sanitation needs
are greatest is based on analyses that have important shortcomings. For example, data are typically aggregated and analyzed at the national level, which
can mask large swaths of people, typically in rural areas and urban slums,
who lack improved services or suffer from water- and sanitation-related disease
Map 4.3
Prevalence of
diarrhea and improved
sanitation, 2000
Source: Data from the United
Nations Childrens Fund and the
Joint Monitoring Programme.
Note: Data on prevalence of improved sanitation are for 2000. Data on prevalence of diarrhea are for various years,
19912000, and indicate prevalence in the two weeks before the survey. The prevalence of diarrhea may vary by season.
Because country surveys were administered at different times, data are not comparable across countries.
Chapter 4
Governments
know much
less about
those who
lack water
supply and
sanitation
services
45
in an otherwise fairly well-serviced, healthy country. Nonetheless, the general

approach used heredening criteria by which groups should be prioritized
and using the best available data to identify where those groups areis one
that should underpin both international and national planning processes.
It is also important in such exercises to be clear about the choice of criteria,
as well as the reasons for and effects of such choices. In this chapter, three alternative sets of criteria for identifying high-need countries are employed that,
in broad strokes, produce a consistent conclusion that high-need countries are
disproportionately found in Africa and Asia. Comparing the lists of specic
high-need countries emerging under each of the three approaches, however,
demonstrates that the choice of criteriaas well as the way in which particular
criteria are operationalizedcan have substantial impact on the way that priorities are shaped (table 4.4). Similar effects are almost certain to occur with
subnational analyses as well.
Pinpointing greatest needs within countries
For water supply and sanitation professionals, it is already common knowledge

that billions of people around the world do not have access to a minimum quantity of safe drinking water and adequate sanitation, and considerable empirical
research has been undertaken to explain the reasons for low coverage rates in
particular communities.2 Governments, however, often know much less about
those who lack water supply and sanitation services compared with those who
do have access. Consequently, while a one-size-ts-all policy for the water
and sanitation sector may appear attractively simple, such an approach may not
reect the supports and strategies needed to reach the unserved.
This section presents a simple typology of six kinds of communities in
which a substantial proportion of households do not have access to improved
water supply and sanitation services (gure 4.1). With respect rst to water
A typology of
communities with
low water supply and
sanitation coverage
Figure 4.1
46
Part 1
Water supply
Table 4.4
High-need countries
identied by
various criteria
Sanitation
Moderate
access and
progress
(UNDP 2003)
Low access,
high diarrhea
incidence
(WHO/UNICEF
JMP 2000)
Low access,
slow progress
(UNDP 2003)
Moderate
access and
progress
(UNDP 2003)
Low access,
high diarrhea
incidence
(WHO/UNICEF
JMP 2000)
Ethiopia
Cameroon
Angola
Benin
Botswana
Angola
Guinea
Madagascar
Cte dIvoire
Burkina Faso
Ethiopia
Burundi
Benin
Malawi
Chad
Central African Cameroon

Republic
Burkina Faso
Mauritania
Namibia
Congo
Guinea
Chad
Congo
Togo
Niger
Eritrea
Madagascar
Cte dIvoire
Eritrea
Nigeria
Ethiopia
Mali
Malawi
Ethiopia
South Africa
Guinea
Mauritania
Namibia
Central African
Republic
Uganda
Mauritania
Niger
South Africa
Chad
Nigeria
Zimbabwe
Mauritania
Low access,
slow progress
(UNDP 2003)
Africa
Togo
Mozambique
Namibia
Niger
Togo
Asia
Papua New
Guinea
China
China
Philippines
India
Bangladesh
Indonesia
Nepal
Pakistan
Papua New
Guinea
Arab states
Oman
Afghanistan
Libyan Arab
Jamahiriya
Sudan
Afghanistan
Yemen

Haiti
Trinidad and
Tobago
Dominican
Republic
Brazil
Haiti
Mexico
supply and then sanitation, a brief description of each community type is provided, along with a summary of the principal explanations for low existing coverage levels, possible strategies for improving coverage, and illustrative examples. Acknowledging that access to water supply and sanitation is a function of
many technical, nancial, and institutional factors, a multifaceted analytical
challenge has been distilled into one with a smaller number of dimensions.
The horizontal axis represents the density of settlement, which carries with it
a host of technical and cost implications for improving access to services. On
Chapter 4
An urban
bias in
infrastructure
investment
policy often
pushes Type I
communities
to the end of
the queue
47
the vertical axis is the range of existing infrastructure. This variable serves as
an indirect proxy for institutional considerations, such as the scope for collective action, based on the assumption that communities with existing but inadequately functioning water-supply infrastructure have a greater institutional
foundation upon which to build than communities where collective water systems have never been installed. This is clearly a simplifying assumption that
will not hold in all cases; however, it is a generalization that is consistent with
experience in many of the case studies described in the following sections.
Efforts have been made to keep the number of categories small; many
nuances in both the community characteristics and the service delivery considerations have thus been omitted. In addition, broader considerations, such
as the status of governance and rule of law, have also been omitted from the
typology. These issues are, however, discussed briey in a separate section.
Across all six community types, unserved households tend to share two
characteristics: they are poor, and they have limited voice in priority-setting
and resource allocation decisions. While neither of these features is unique to
the water and sanitation sector, each has important implications for the kinds
of strategies needed to improve water supply and sanitation coverage to meet
target 10.
Access to domestic water supply services
Water supply coverage is a function of both demand and supply considerations
in each typology category.3 For each community type, a summary of the principal demand considerations is presented, followed by a synopsis of the principal supply issues.
Type I: dispersed settlement, little or no improved infrastructure. Type I communities tend to be found in rural areas with agrarian economies. Household
memberstypically women and childrenobtain water for domestic uses
from surface water sources, and occasionally from water vendors. The time
devoted to water fetching is often substantial, and both quantity and quality
of water supply is lacking.
The reasons for lack of access to adequate supplies of water in Type I communities are found both in the economics of water supply and in development
policy frameworks at the national level. Such settlements are generally unable
to exploit economies of scale for community-level water supply solutions, so per
capita costs of improvements are high, while the potential for cash contributions
from households tends to be low. At the provincial and national level, an urban
bias in infrastructure investment policy often pushes Type I communities to the
end of the queue for government-nanced water supply improvements.
Facilitating water supply improvements in Type I communities often
requires substantial investment in institutional capacity building before sustainable improved water supply infrastructure can be installed. Frequently, the
48
Part 1
Flexible
strategies
that allow
in-kind
contributions
such as
labor may be
important
in Type I
communities
institutions needed to facilitate collective action for improving water supply are
weak or completely absent. Partnerships with national or even international
nongovernmental organizations (NGOs) may be necessary to develop community capacity for organization and planning of improved services.
If cost-sharing policies exist, exible strategies that allow in-kind contributions such as labor may be important in Type I communities, where cash
tends to be scarce. Another strategy for addressing the cost issues of water
improvements in such communities is to consider the possibility of combining
irrigation and domestic water supply initiatives. Millions of people throughout
the developing world obtain their household water from irrigation facilities, yet
planning and policy for irrigation is carried out largely without consideration
of domestic users. Exploring the possibilities for incorporating both irrigation
and domestic needs into water planning has the potential in many cases to
lower costs, to replace environmentally damaging practices (such as tubewell
irrigation, which can deplete water tables) with more sustainable ones (such as
drawing seepage from irrigation canals through handpumps), and to ensure
that the water people end up drinking is safe.4
Type II: dispersed settlement, existing infrastructure providing inadequate supply.
Type II communities have some type of improved water supply infrastructure
installedtypically shared facilities, such as borewells with handpumpsbut
are considered to be lacking access to services because the volume of water supplied per capita is insufcient or because the facilities have fallen into disrepair.
Households either manage with these small quantities of water or supplement
them with water from surface sources or vendors.
The water supply infrastructure in Type II communities has often failed
because of inadequate maintenance. (Population growth in the community
may also contribute to declining per capita supplies.) The public investment
neglect and affordability issues that Type II communities suffer has been overcome, at least initially, but sustainability of the installed infrastructure is lacking as a result of inadequate nancial resources for operation and maintenance,
unavailability of spare parts or technical skills, a weak institutional arrangement for upkeep of the facilities, or some combination of those factors.
Understanding the reasons for the poor performance of a Type II communitys water infrastructure is a critical rst step in improving coverage. If
the level of service installed is too expensive to be maintained by users, simply rehabilitating the existing infrastructure will result in another failure in
the future. Even if the economic capacity for operation and maintenance does
exist within the community, a different sort of mismatch between supply and
demand may exist. In the village of Vellukara, India, for example, a piped
water system with shared public taps fell into disuse because half of the villages
households preferred to use private or shared wells (Davis and others 2001).
These households were also unwilling to pay monthly fees toward the upkeep
Chapter 4
The water
supply
infrastructure
in Type II
communities
has often
failed
because of
inadequate
maintenance
49
of the system, which rendered it nancially unviable and left the other half of
the village reliant on distant surface water sources. This case illustrates how
critical it is to understand the realities of demand for different types of facilities
before embarking on projects.
Poor system performance may also arise if the communities lack the human
capacity and training to maintain the supply systems in good working order.
In the case of Ghana, for example, rural communities had historically not been
a part of the planning process for water supply and thus had neither a stake in
nor the capacity to ensure the longevity of the installed handpumps and piped
systems. By one estimate, 60 percent of these facilities were nonfunctional at
any given time before Ghana initiated major sector reforms in the 1990s (Kleemeier 2002). Accounts of this sort are very common, particularly in countries
with weak local administrations. By extension, sustainable coverage expansion in Type II communities often requires considerable focus on training and
building the capacity of local institutions.
In Ghana, for example, capacity building was undertaken gradually, with
core planning functions transferred from central government to local government and communities. Ownership of water supply was transferred to the
local governments and the communities. A number of public and private organizations brought their strengths to the new project, including four drilling
companies, 32 local NGOs and community-based organizations, and several
national and international NGOs. In Togo, a redesign of one of the countrys
largest rural water supply programs included strengthening of social intermediation programs and training of community technicians. In one village,
Ayolewhere a previous government-installed community handpump had
broken downa rehabilitation project was accompanied by technician training, the formation of a committee responsible for raising funds for operation
and maintenance, and earmarked public funds at the district level for the provision of spare parts and extension services. The result was a well-functioning
handpump and a community that, one year after its rehabilitation, successfully
overcame a major failure of the pump (UNDP 1988).
It is important to note, however, that building capacity at the local level
does not mean that central government has no role to play in sustainable service delivery. Indeed, the balance between the center and local service providers is critical to maintaining effective and reliable services. Whereas the
prevailing wisdom in the development community advocates decentralization
of water and sanitation services to the lowest possible level, empirical evidence increasingly indicates that centralized institutions may be best suited to
executing particular tasks within service planning, delivery, and monitoring.5
For example, in one rural supply project in Azad and Jammu Kashmir, Pakistan, it was a set of centralized oversight mechanisms that ensured sustainable
scheme designs and prevented disadvantaged groups from being excluded from
project benets (Davis 2003). In addition, realizing economies of scale in bulk
50
Part 1
Type III
communities
are generally
large enough
to enjoy some
economies
of scale
water provision may require a lead agency at a higher level than the community. Furthermore, institutions not based in the community can be helpful in
ensuring that the externalities of service provision do not simply get passed on
to neighboring communities.
Centralized agencies may also need to provide ongoing support to local
administrations and service providers undertaking responsibility for water supply for the rst time. A growing literature also suggests that Type II communities need considerably more support after the construction phase of a project
than was previously believed. Resources and capacity to provide training, technical assistance, and supply-chain support to communities must be available
in the long term, whether through local government, NGOs, or external agencies. Because such software components of water supply planning receive
much less emphasis (and funding) than do more visible construction projects,
these elements so critical to sustaining installed infrastructure are often the
most difcult to establish.
Type III: medium density, little or no improved infrastructure. Type III communities often represent the interface between rural and urban settlements
villages that have grown into small towns, but whose infrastructure systems
have not yet evolved to a level comparable with larger cities. Some wealthier
households may have installed private wells, while a substantial proportion of
families obtain water from vendors or surface water sources.
Type III communities are generally large enough to enjoy some economies
of scalewhich means that piped networks will be feasible in at least part of
the settlementbut are too small or dispersed for traditional urban utility
management models to operate effectively. There often exists in Type III communities the economic capacity to make considerable improvements in water
supply, but the absence of a supportive institutional framework often results in
a variety of household-level solutions as opposed to a coordinated communitylevel effort. Type III communities are generally excluded both from national
water supply programs targeting rural areas and from those focused on cities. Local government institutions are often weak and under-resourced. Few
households have access to credit.
Extending coverage in Type III communities can happen quickly and sustainably, but planning mistakes are easy to make in this type of settlement.
In particular, the question of whether such communities should be viewed
more like large rural villages or small cities has considerable implication for
the technologies and management structures that will be adopted. In the town
of Lugazi, Uganda, for example, a piped network was installed, which provided private connections to a substantial proportion of households, as well as
a limited number of public kiosks in the central business district. Households
that once used spring water now obtain water supply from their own or their
neighbors private connections, from public kiosks, or from vendors who also
Chapter 4
Extending
coverage
in Type III
communities
can happen
quickly and
sustainably
51
patronize the kiosks. In all cases, users pay the full cost of the level of service
they receive. In the neighboring town of Wobulenzi, the water-planning paradigm was more like that of a rural village. Water user groups were established
and were given responsibility for managing neighborhood kiosks throughout
the town, and most established prices that were lower than the cost of supply.
Private connections were also made available to households and businesses that
wished to pay the full cost of this improved level of service. These two very
different models stemmed from fundamentally different views of the character
and the future of the communities and gave rise to two unique sets of nancial
and institutional challenges (Wandera 1999; Whittington and others 1999).
Much less is known about effective strategies for extending sustained coverage in small towns, as compared with either rural or dense urban settlements.
It appears that allowing for a variety of service options and expecting the composition of technologies to change rapidly are important planning principles in
these dynamic communities. Considerable empirical research has also demonstrated that provision of nancingeven at market ratescan unleash latent
demand for improved services and allow households in small towns to move
more quickly toward community-level piped networks. In towns where such
economic capacity does not exist, policies that promote small-scale independent providers can also increase the range of options available to households
and lower service costs through competition and innovation (Collignon and
Vezina 2000). Growing recognition of the policy vacuum regarding water supply and sanitation services for Type III (and IV) communities has spurred
several important research and policy-experiment activities. In Peru, for example, the Water and Sanitation Program is currently undertaking comparative
analysis of several different management models in a number of small towns
(Water and Sanitation Program website).
Type IV: medium density, existing infrastructure providing inadequate supply.
Small towns in the Type IV category have installed water supply facilities
that provide an insufcient volume of water per capita per day. Households
typically supplement their water supply with water purchased from vendors
or perhaps drawn from surface sources. If the level of community-level service
continues to slide, wealthier households will tend to exit the public system in
favor of self-provision (for example, through private wells). Over time, the situation deteriorates as revenues decline, and households with the greatest ability
to withstand tariff increases (and provide cross-subsidies to poorer households)
invest in private solutions instead.
As with Type II communities in rural areas, it is important to understand the
reasons that existing infrastructure in Type IV towns is not providing adequate
supply. Simply rehabilitating a poorly designed system will not provide sustained
access to improved services in the long run. In many cases, small town systems
are overbuilt as a result of designs based on perceived demand and peak estimates,
52
Part 1
A variety of
institutional
models
are being
employed to
improve water
services
in Type IV
communities
rather than on dialogue with users themselves. Although technically sound, such
systems cannot be supported given the economic base of the community. In
Mali, for example, the overscaled design of facilities was identied as one of the
key explanations for the high rates of failure in small-town water systems.
The unsustainability of overbuilt systems can be further exacerbated by the
institutional arrangements for water supply services that are typically found in
small towns. Services managed by local government may suffer from undernancing, particularly for operation and maintenance, when funds for water are
intermingled with the communitys general accounts. Water user associations
or other civic groups dedicated to water supply service delivery may perform
better with respect to nancial and accountability matters, but they often lack
technical capacity and have limited access to state or national sources of support in the event of major problems.
A variety of institutional models are being employed to improve water services in Type IV communities, from regional utilities in South Asia to local
juntas in Latin America. There is also increasing private-sector involvement in
the management of small-town water systems. In Uganda, the national government nanced the rehabilitation of several dozen Type IV towns as a prelude to
establishing management contracts with six private operators (Kayaga 2003).
The World Bank is also supporting pilot projects in franchising for small town
water systems (Roche and others 2001).
Type V: high density, little or no improved infrastructure. Urban areas lacking
water supply infrastructure typically fall into two categories: newly constructed
neighborhoods to which trunk lines have not yet been extended or unregularized areas where the installation of trunk infrastructure is costly or prohibited
by law. Households in Type V communities typically obtain water from vendors (ranging from pole vendors to tankers); from privately or communally
managed stationary tanks; or from friends, family, or employers located in
networked areas.
In areas of new construction, urban development policy and regulation is
typically the cause of lack of access. Development permits, for example, may be
granted without the requirement of providing basic services. Indeed, at times,
urban development authorities actually work at cross purposes with water and
sanitation agencies. In Lima, Peru, for example, a decision of the Vice Ministry for Construction and Sanitation that inadequate water supply was available to develop an outlying area of the city was overturned by the Ministry of
Housing, which was under strong political pressure to develop new areas for a
national low-cost housing program (Davis 2004).
In urban slumsdened as unplanned areas in which the majority of residents have title neither to their land nor their homesboth the high cost of water
supply improvements and an unsupportive policy environment constrain access
to service. Such settlements are often located on marginal lands at considerable
Chapter 4
In many
cases, efforts
to improve
water supply
services
in Type V
communities
are frustrated
by policy
constraints
53
distance from trunk infrastructure, with steep slopes, rocky or hilly terrain,
and irregular layouts. The per capita cost of networked water supply improvements is high, as is the risk of damage to installed systems (through landslides or
oods, for example). Even if households were able to bear most of the costs of an
improved system, service providers are often prohibited from extending networks
into unregularized areas. Municipal and state governments use proscriptions,
such as urban growth management tools, hoping to discourage the expansion of
squatter settlements in already overburdened cities. In other cases, service providers have the authority to extend services to such neighborhoods, but are reluctant
given the high costs and perceived risks to investments, as well as the perception
of low revenue potential among poor and transient households.
In many cases, efforts to improve water supply services in Type V communities are frustrated by policy constraints at various levels. Where network
services cannot be installed, promoting alternative service options is often the
most feasible way of improving households water supply situation. Mobile
delivery systems, such as the aguateros in Latin America and tankers in South
Asia, are two such examples (Solo 1999). In some cases, collaboration between
the municipal water supply and sanitation agency and local entrepreneurs
is another strategy for improving services. In Abidjan, vendors install water
lines at the limit of the municipal water companys service area and operate
standposts in the citys outlying, unregularized areas (Mitter 1999). Such solutions are often less efcient than piped service and can result in households
receiving poor quality service and yet paying very high unit prices (Lovei and
Whittington 1993). Where the service-delivery environment is competitive or
effectively regulated (for example, through involvement of credible civic organizations), these appropriate technology approaches can represent a workable
strategy for providing reliable water services to Type V households.
Type VI: high density, existing infrastructure providing inadequate supply. Type
VI settlements are often considered by municipal governments and water and
sanitation agencies to be covered with improved service (typically through
shared public sources), whereas independent assessments of coverage document a high proportion of households receiving very small volumes of water.
In Hyderabad, India, for example, households in many colonies served by public taps were found to receive only 20 liters per capita per day (lpcd) on average, compared with 135 lpcd provided to households with private connections
(Davis and others 2001). The citys water and sanitation agency, however, does
not classify the 20-lpcd households as lacking access to services. Households
in Type VI communities may supplement their water supply with purchases
from vendors or from other households with private connections.
The factors underlying inadequate water supply in Type VI communities
are somewhat more varied than with other categories in the typology. In some
cases, technical explanations are important, as when a distribution network has
54
Part 1
Strategies
for improving
water supply
services
in Type VI
communities
must be
tailored to
constraints
on the ground
deteriorated to the point that it can supply only a minimal quantity of water
each day. In other cases, improved services are available, but households cannot
or do not take advantage of them. A large proportion of households may live in
rented homes, for example, and may be reluctant (or prohibited by landlords)
from investing in private household connections. Households may be willing
and able to afford the monthly fees associated with improved services, but may
not have the credit necessary to pay for up-front installation and plumbing
costs.6 In addition, service providers often afford Type VI communities low
priority in their planning and budgeting processes, both because such neighborhoods are perceived as having little revenue potential and difcult working
conditions and because they have limited political clout compared with more
afuent parts of the city.
Strategies for improving water supply services in Type VI communities must
be tailored to the particular constraints encountered on the ground. Where
trunk infrastructure exists but households are unable to afford connections or
monthly fees, targeted subsidies and credit programs can have a large impact.
If large-scale rehabilitation or installation of trunk infrastructure is a necessary
precursor for expanding coverage, access to nancing at the municipal level is
essential. In either case, there may be scope for improving access to services in
the shorter term through the promotion of small-scale independent providers
(as described for Type V communities above). Because the relationship between
households in Type VI communities and their service providers is often characterized by a lack of trust, bringing credible third parties into the institutional
arrangements for planning, construction, and service delivery can also be an
effective strategy. In Ahmedabad, India, three well-known NGOs partnered
with the Municipal Corporation to implement an upgrading project in 27 lowincome neighborhoods (Davis and others 2001). Not only did the NGOs provide critical nancial intermediary services for the project, but their staff helped
both households and Municipal Corporation staff to appreciate one anothers
perspectives and constraints (Davis and others 2001). The key elements of the
preceding discussion on domestic water supply are summarized in table 4.5.
Access to domestic sanitation services
When applying the typology presented in gure 4.1 to the case of sanitation
services, two interrelated observations quickly emerge. First, despite the fact
that sanitation arguably represents a service with greater public-good characteristics than does water supply, in practice sanitation is often regarded as a private household matter, organized and nanced by users, whereas water supply
commands considerable attention in the public policy and planning sphere.
This view of sanitation services leads to a second observation, namely, that the
key leverage points in expanding sanitation coverage should involve generating
demand and inuencing decisions made at the household level. Together, these
insights would suggest a rather different set of policy and planning strategies
Chapter 4
Table 4.5
Typology of unserved
and underserved
communities for
water supply
Density
Existing
service
55
Proximate explanations
Supply side
Demand side
Possible policy
and planning
responses
Dispersed
(rural)
Little or no
improved
infrastructure:
supply from
vendors and
surface water
sources
Limited public
investment
in rural water
supply.
Perception
of poverty.
High per
capita cost.
Capacity
Poverty.
building and
Limited access
development of
to credit.
collective-action
Challenges of
institutions.
collective action.
Combined
Low demand:
agricultural
availability of
and domestic
acceptable
water projects.
alternatives.
Partnerships
with civic
organizations.
Targeted
subsidies.
II
Dispersed
(rural)
Inadequate
supply from
shared public
facilities,
such as
borewells with
handpumps
Limited
investment in
operations,
maintenance,
and expansion.
Perception
of poverty.
Capacity building,
Poverty.
and transfer
Limited access
of planning
to credit.
Challenges of
or budgeting
authority to
collective action
local bodies.
for operation and
Capacity building
maintenance.
at national level
Low demand:
for long-term
availability of
acceptable
community
alternatives.
support.
Partnerships
with civic
organizations.
Targeted
subsidies.
Programs to
strengthen
supply chains.
III Medium
Supply from
density
private
(small town) household
facilities,
vendors, and
surface water
sources
Limited public
and private
investment
available for
small town
water supply.
Policy vacuum.
Limited access
Policy
to credit.
development.
Demand captured Development of
by private
collective-action
household
institutions.
investment.
Promotion of
small-scale
independent
providers.
Management
innovations
(franchising,
regional utilities).
Targeted subsidy
and credit
programs.
IV Medium
Supply from
Inadequate
density
dysfunctional
resources and
(small town) public networks
capacity for
operation and
maintenance of
public system.
Policy vacuum.
Limited potential
for use of voice.
Unwillingness
to pay higher
tariffs for lowquality service.
Higher-income
households may
exit system.
Capacity
building for
operations and
maintenance.
Policy
development.
Promotion of
small-scale
independent
providers.
Management
innovations
(franchising,
regional utilities).
Targeted subsidy
and credit
programs.
56
Part 1
Table 4.5
and underserved
communities for
water supply
(continued)
Density
V
Existing
service
High density Little or no

(urban or
improved
periurban)
infrastructure:
supply from
vendors
VI High density Supply from

(urban or
shared public
periurban)
facilities
Supply side
Demand side
Possible policy
and planning
responses
Growth (newly
incorporated
areas).
Investment
restrictions in
unregularized
areas.
High per
capita cost.
Perceptions
of poverty.
Constraining
standards.
High proportion
Urban
of rented
development
dwellings.
policy reform.
Insecure tenure. Promotion of
Challenges of
small-scale
collective action.
independent
providers.
Partnerships
with civic
organizations.
Targeted subsidy
and credit
programs.
High per capita

cost of supply.
Perceptions
of poverty.
Constraining
standards.
Promotion of
High proportion
small-scale
of rented
dwellings.
independent
Challenges of
providers.
collective action. Partnerships
with civic
organizations to
promote dialogue
with provider.
Targeted subsidy
and credit
programs.
to expanding sanitation as opposed to water-supply coverage. But this view of

sanitation is too restrictive. In reality, private sanitation is but one of three key
components of sanitation: private or domestic, community or neighborhood,
and public levels of sanitation. Thus, sanitation policy and planning should
take all three into consideration. In highly dispersed settlements, what matters
is often private sanitation. Hence, the appropriate point of intervention would
be at the household level. For large congested settlements, all three components
are important. In such situations, the appropriate points of intervention would
be at the community or neighborhood level and at the public level. Between the
two extremes, a range of options may be appropriate.
Type I and II communities: dispersed settlements, little or poorly functioning
infrastructure. Given the high rates of poverty, limited or complete absence of
institutions dealing with sanitation in rural areas, and the use of traditional
sanitation practices (such as defecation in agricultural croplands), effective demand for improved sanitation in rural communities is often very low.
Effective demand can have a gender dimension, as well. Research has shown
that women place a higher value on household toilets that men do (Mukherjee 2001); lack of effective demand can thus sometimes be traced to both an
unwillingness on the part of male family heads to prioritize paying for sanitation services and the lack of female voice in dening spending priorities and
community actions.
Efforts to boost demand for improved sanitation must be carefully planned.
In some projects, for example, households have been required to install latrines
Chapter 4
Awareness
campaigns
need to make
better use
of modern
marketing
strategies
57
as a prerequisite for receiving improved water supply. Although this bundling

strategy has been successful in some communities, in others it has led to the
construction of white elephants that households have little interest in using
or maintaining.
In some cases, communities understanding of the links among sanitation,
hygiene, and health is limited, and awareness-raising efforts can help generate
demand for improved sanitation services. In many other instances, however,
households have simply pursued other investments in a rational priority-setting
process. Awareness campaigns may need to take greater advantage of modern
marketing strategies, focusing on basic human emotions, such as pride, shame,
and competition to make real progress in rural sanitation. Such programs could
also, where feasible, provide information about the potential for human waste
to be used as a resource in agriculture. Some sanitation technologiessuch
as the twin-pit latrineare well suited to the collection and safe removal of
excreta, which can be applied as fertilizer to crops.
Subsidies for improved sanitation services have been declining in recent
years. For Type I and II communities, the costs of simple technologies may be
low, but so too is effective demand for them. Improving affordability with welldesigned subsidiespaired with social marketing effortsmay be more costeffective than implementing large-scale education and marketing campaigns
in an effort to inuence household investment decisions. Recent experience
with a particularly promising approach called community-led total sanitation
suggests that, in some instances, subsidies can inhibit community action. In
community-led total sanitation, communities themselves analyze the effects of
open defecation and address the problem by building latrines cheaply from local
materials and establishing community mechanisms for ensuring that everyone
uses them. When community members think that a subsidy may be in the offing, they do not participate in the community effort. It is important to stress
that this approach has been successful in rural areas, with basic latrines made
from often freely available local materials and volunteer community labor; this
no subsidies approach may not be applicable in areas where latrines cannot
be constructed so inexpensively, such as urban slums.
Type III and IV communities: medium density, little or poorly functioning infrastructure. As is the case with water supply, sanitation planning at the ruralurban interface can be particularly challenging. Households in these communities have often been exposed to sewerage systems and would appreciate
the convenience and status that toilets with sewers would convey. However,
these are costly technologies, and on-site facilities may be a more appropriate choice given the economic base of the community. In some small towns
in Peru, for example, fewer than 10 percent of households have connected
to piped sewerage networks, although the results of community assessments
indicated this level of service was preferred by a majority of residents (Davis
58
Part 1
Communities
at the
urban-rural
boundary
are also
often good
candidates
for recycling
sewage water
in agriculture
2004). Once households were confronted with the substantial connection fees
and monthly service bills, however, a majority decided to retain their existing
(on-site) service.
It may be possible to respond to the demand for sewerage service in Type
III and IV communities by adopting lower-cost technical options. In Brazil,
for example, a system of condominial sewerage was developed in the 1980s
with the aim of extending sanitation services to low-income communities. This
technology has now become a standard sanitation solution for entire urban
areas in Brazil, irrespective of income levels. Condominial sewers reduce per
capita costs of service by replacing the traditional model of individual household connections to a public sewer with a model in which household waste is
discharged into branch sewers, and eventually into a public sewer through a
group (or block) connection (Watson 1999).
For households that cannot afford a sewer network connection, public
facilities may be a good alternative, if they are carefully designed. Countless
anecdotes exist in the water and sanitation sector regarding public facilities
that, once constructed, quickly fell into disrepair because communities lacked
the interest or skills to maintain them. Examples do exist, however, of public facilities that function reliably and are well maintained. They all have the
common feature of having in place attendants who take care of them, as well
as being operated on a pay-per-use basis. In India, the NGO Sulabh International has installed 5,500 pour ush toilets that are operated on a fee basis and
are maintained by attendants who live at the facilities. Through gradual technology development, careful attention to sustainability, and strong efforts in
marketing and promotion, Sulabhs facilities are considered to be a model for
sustainable public sanitation services (Sulabh International website).7
Communities at the urban-rural boundary are also often good candidates
for recycling sewage water in agriculture (Ensink and others 2002). This practice can save enormous costs of treating sewage water, while creating substantial benets in the form of usable water and fertilizer for agriculture. Care must
be taken to ensure that the concentration of fertilizer nutrients in the water is
not too high, and agricultural workers using recycled sewage water should also
be equipped with protective gear, such as gloves and boots. In sum, although
recycling sewage water in agriculture is not without its problems, these problems can be managed. The savings in water treatment and the benets in food
production make this practice highly desirable.
Type V and VI communities: high density, little or poorly functioning infrastructure. Improving sanitation in urban areas is perhaps one of the most formidable
challenges facing target 10 and the water and sanitation sector more generally.
Given the high densities of these communities, on-site technologies are often
unworkable because of limited land availability and the potential for contamination of drinking water supplies. Sewerage systems, on the other hand, are
Chapter 4
The high per

capita cost
of sanitation
services
is often
the result
of overly
stringent
technical
standards
59
expensive to construct and can generally not be operated and maintained with
revenues obtained from low-income households. As with water supply services,
challenges related to insecure tenure and landlord-tenant arrangements often
undermine efforts to improve sanitation services in these communities.
In many instances, the high per capita cost of sanitation services is the
result of overly stringent technical standards adopted without modication
from industrial countries.8 In the past decade many innovative technical solutions have helped resolve this bottleneck to expanding sanitation coverage.
Condominial sewerage (discussed above) is one example of a lower-cost technology that has been successful in some areas. Another technical innovation
involves unbundling of sewer networks into several smaller systems serving
different zones within a city. In Bangkok, Thailand, for example, the Metropolitan Administration prepared a wastewater master plan for the entire metropolitan area in 1968. Though technically sound, the plan was found to be
prohibitively expensive and was shelved for 16 years. In 1984, the master plan
was revised under a Japanese technical assistance program such that the inner
part of Bangkok was divided into 10 sewerage zones, each with an independent
collection and treatment system. The total sanitation investment among the
10 zones is lower than the amount that would be required for a single project
that covered the entire city. Moreover, each zone-level project is technically
simpler than a citywide project would be. As a result, the Bangkok Metropolitan Administration has been able to implement various sanitation projects in
different zones of the city, using a more affordable phased investment program.
(For more details, see the case study in the appendix to this volume).
In much of the literature on urban sanitation, institutional constraints are
considered to be as important as technical and nancial challenges in explaining low rates of coverage. Whereas low-income urban communities tend to
have more inuence than, say, dispersed rural villages, they still often lack the
capacity for organizing, planning, and levying demands on government and
service providers. For their part, municipal water and sanitation agencies often
nd it difcult to initiate a dialogue with low-income communitiesand
often have little incentive to do so. Partnerships between government, service
agencies, communities, and civic organizations can thus be useful in facilitating dialogue and collective action in pursuit of improved sanitation services
for the urban poor.
In West Bengal, India, for example, the Medinipur District Rural Sanitation Project was launched in 1990 and involves UNICEF, state- and district-level governments, a religious NGO (the Ramakrishna Mission), and
voluntary grassroots community-level organizations. The project was designed
as a peoples movement and strives to discourage open defecation through
education and social marketing. Community mobilization and education is
carried out by trained motivators from the communities, using home visits,
60
Part 1
motivational camps, exhibitions, and the use of visual aids, such as ash cards
and calendars.
Over the course of just 10 years, the project has increased coverage of improved
sanitation services from almost zero to 80 percent. Development and production
of the latrines was undertaken locally, which improved cultural appropriateness
and affordability of the designs while also providing an economic opportunity
for local women trained in latrine component manufacturing. To date, approximately 1.2 million latrines have been delivered through the program throughout
West Bengal. The impact of widespread latrine development has been accompanied by a remarkable reduction in cases and deaths associated with diarrheal
diseases (Chowdhry 2002; Sengupta 2001; UNICEF 1994, 2002).
For countries with very low access to basic sanitation, increasing the effectiveness of management of excreta at the household level may have the biggest
health implications, and it may be the biggest challenge. For this reason some
countries may legitimately decide to focus their efforts at this level in the short
Table 4.6
and underserved
communities for
sanitation
Density
Existing
service
Supply side
Demand side
Possible policy
and planning
responses
Dispersed
(rural)
Little or no
improved
infrastructure:
open
defecation
No institutional
home for
sanitation.
Low priority and
limited public
investment in
rural sanitation.
Poverty.
Limited access
to credit.
Low demand
for sanitation
improvements.
Social marketing
and education.
Partnerships
with civic
organizations.
Targeted
subsidies and
credit programs.
II
Dispersed
(rural)
Service from
dysfunctional
private
facilities, such
as latrines
Poverty.
No institutional
Limited access
home for
to credit.
sanitation.
Low demand
Limited postfor sanitation
construction
improvements.
support for
sanitation.
Limited privatesector skills for
operation and
maintenance.
Mismatch
between levels of
service supplied
and demanded.
Social marketing
and education.
Partnerships
with civic
organizations.
Targeted
subsidies and
credit programs.
No institutional
home for
sanitation.
Limited
resources
available for
operation and
maintenance.
Constraining
standards
for service
improvements.
Social marketing
and education.
Partnerships
with civic
organizations.
Regulatory reform
(standards, new
construction).
Innovative
technologies.
III Medium
Service from
density
dysfunctional
(small town) private
and public
facilities,
open
defecation
Limited access
to credit.
Limited demand
for sanitation
improvements.
Demand captured
by private
household
investment.
Chapter 4
61
term. In other cases specic linkages between elements of sanitation mean

that a more complete solution may be better. For example, in a particularly
congested urban community some form of off-site (sewered) sanitation may
be the only viable technical choice, in which case there will probably need to
be some interventions to improve management of solid wastes and stormwater
drainage; otherwise the sewers wont work.
The key issue is that each community, region, or country needs to work
out the most sensible and cost-effective way of thinking about sanitation in
the short and long term and then act accordingly. Flexibility and pragmatism
should be the key wordsand both professionals and politicians need to try
to see past experience and ideas that are developed elsewhere. A pragmatic
local approach with an eye to wider environmental and health issues is likely
to result in more progress than blind adherence to a rigid global denition.
The key elements of the preceding discussion on sanitation are summarized
in table 4.6.
Table 4.6
and underserved
communities for
sanitation
(continued)
Density
Existing
service
Possible policy
and planning
responses
Supply side
Demand side
IV Medium
Service from
density
dysfunctional
(small town) private
facilities
No institutional
home for
sanitation.
Limited postconstruction
support for
sanitation.
Limited access
to credit.
Limited demand
for sanitation
improvements.
Demand captured
by private
household
investment.
Social marketing
and education.
Partnerships
with civic
organizations.
Regulatory reform
(standards, new
construction).
Innovative
technologies.
No institutional
home for
sanitation.
Growth (newly
incorporated
areas).
Investment
restrictions in
unregularized
areas.
High per capita
cost of service.
Perceptions
of poverty.
Constraining
standards.
High proportion
of rented
dwellings.
Insecure tenure.
Limited access
to credit.
Poverty.
Low demand
for sanitation
improvements.
Land tenure
reform.
Social marketing
and education.
Partnerships
with civic
organizations.
Regulatory reform
(standards, new
construction).
Innovative
technologies.
No institutional
home for
sanitation.
High per capita
cost of household
level supply.
Perception
of poverty.
Constraining
standards.
Limited funding
and incentives
for operation and
maintenance.
High proportion
of rented
dwellings.
Limited access
to credit.
Poverty.
Low demand
for sanitation
improvements.
Land tenure
reform.
Social marketing
and education.
Partnerships
with civic
organizations.
Regulatory reform
(standards, new
construction).
Innovative
technologies.
High density Little or no

(urban or
improved
periurban)
infrastructure:
open defecation or use of
facilities in
other neighborhoods
VI High density Service from

(urban or
shared public
periurban)
facilities
Chapter 5
Whats holding us back?
To understand how to move forward to meet the Millennium Development

Goals, it is rst necessary to analyze whats holding us back. Understanding
why 2 in every 10 people in the developing world lack access to water supply,
and 5 in 10 lack access to sanitation services, is fundamental to identifying
effective strategies for meeting target 10. Clearly, the explanations vary across
communities, countries, and regions, but a common set of political, nancial,
institutional, and technical challenges confronts most developing countries in
their quest to expand water supply and sanitation services.
Political constraints
One of the chief constraints to expanding water supply and sanitation coverage
is the lack of political will, by which we mean an absence of political leadership
and government commitment to allocating sufcient national resources to the
sector, and to undertaking the reforms necessary to improve performance and
attract investment (box 5.1).1
There are many underlying reasons for a lack of political will. For decisionmakers in nance ministries, for example, investments in water supply and
sanitation are perceived as having lower returns than funds spent in other sectors (for example, on roads or energy). Another reason is the failure of technical
specialists, civil society actors, and others to make a compelling case to decisionmakers concerning the social and economic benets of access to water supply and sanitation services. It is easier to make the case where political leaders,
as well as policy and decisionmakers, are themselves aware or convinced of the
social, economic, environmental, and spiritual benets from access to water
supply and sanitation. Politicians, in particular, tend to respond to public pressures and demands from their constituencies; hence, they tend to give higher
priority to water supply in response to higher demand for water. Experience
Chapter 5
Information
can be one
of the most
effective
tools for
overcoming
political
resistance
Box 5.1
Water is a
political issue
63
shows that where political leadership and commitment have been accompanied
by social marketing, signicant progress has been made not only in access to
water supply, but also to sanitation.
The capture of water and sanitation planning and institutional processes
by powerful political interests also acts as a barrier to service expansion. The
kinds of changes needed to prioritize improved water supply and sanitation
services to poor households often threaten status quo arrangements that confer
substantial benets on politically inuential groups. The resistance that often
emerges can be difcult to overcome, particularly when vested interests exploit
the plight of the unserved to argue against policy or institutional reforms.
Building broad-based, informed coalitions, ideally led by an inuential political champion, is critical for mounting initiatives that prioritize the poor and
redirect resources toward low-income households.
Indeed, information can be one of the most effective tools for overcoming
political resistance. Decisionmakers often need education about the social and
economic benets of improving water supply and sanitation to make a case
for prioritizing the sector in policy and planning processes. Public education
campaigns, such as the report card and public meeting approaches employed
in parts of South Asia, can help mobilize broad support and exert pressure
for change on elected ofcials. Equally important, civic organizations and the
public need information regarding the ways in which existing subsidies are
captured by middle- and upper-income households and prevent expansion of
service to the poorest.
Broad policy and institutional reform is also essential for reducing political
interference in the day-to-day operations of water and sanitation agencies in
many countries. So long as water supply and sanitation service providers are
reliant upon the state for budgetary transfers, and so long as agency staff are
vulnerable to interference by ofcials in decisions related their careers, priority
setting, pricing, and investment will continue to favor those with political connectionswhich almost never includes the poor. Ring fencing2 of agencies
to help make nancial and personnel management processes more transparent
Local elections took place two months back. Our only demand was waterwhoever gave
us water would get our votes.
Sagira, a pavement dweller in Mumbai, India.
For a few weeks before the municipal elections, one of the candidates who lives just on the
other side of this hill used to supply water to us in long hosepipes from taps in his house.
After the elections, the hosepipes disappeared and our water supply stopped. Now if we go
to him to ask for water he drives us away as if we are beggars. It is so humiliating!
A woman from Laxminagar, a slum settlement of about 700 families in Pune, India.
64
Part 1
Condencebuilding
measures
can help
pave the way
for deeper,
subsequent
reforms
and less vulnerable to corruption, as well as the enactment of civil service legislation to improve incentives for good performance, are two examples of the
kinds of reforms that can help reorient planning and decisionmaking toward
communities with relatively weak political voice.
It is also worth noting that, in the water and sanitation sector, change is
often triggered by a crisis, such as a drought, a precipitous drop in service levels, an outbreak of disease, or a nancial failure. Political shifts, such as decentralization or elections, can also be opportunities for reform, as can external
shocks, threats, and opportunities, such as the possibility of privatization or
donor pressure. Indeed, timing is one of the basic challenges of the sector
how to make progress within one political cycle after decades of neglect or how
to interest politicians in measures that are not likely to yield visible results during their terms of ofce. It is thus important to look for historic opportunities
to make large strides and also to pursue buy-in around a few simple rst steps
that can yield short-term benets to the politicians and policymakers. Such
condence-building measures that build capacity, trust, and social capital
can help pave the way for deeper, subsequent reforms (Kingdom and Van Ginneken 2004).
Institutional constraints
Two types of institutional constraints3 stand in the way of expanding access

to water supply and sanitation services: the lack of appropriate institutions at
all levels, and chronic dysfunction of existing institutional arrangements. At
the community level, potential users of services are often constrained by the
absence or underutilization of institutions to facilitate collective or individual
action. At the national and subnational level, sanitation often has no institutional home at all, creating a policy vacuum and a corresponding lack of
prioritization in budgetary decisionmaking.
Among existing institutions involved in the extension, operation, and
maintenance of water supply and sanitation servicesincluding formal organizations such as utilities and local governments, less formal associations such
as village committees, and principles or practices such as laws, regulations,
and customspersistent problems at the heart of constraints to expanding
access to service include inadequate capacity, inappropriate incentives, lack of
accountability, and absence of a sound regulatory system. are. For women,
legal barriers to owning and inheriting land can also serve to limit their access
to water.
Capacity building
Institutions responsible for service provisionwhether village water and sanitation committees or large urban utilitiesneed technical, nancial, managerial,
and social intermediation capacity that is lacking in many parts of the developing world. Technical capacity is particularly critical for extending services to
Chapter 5
Capacity
building is
also essential
in the area
of gendersensitive
programming
and
policymaking
65
low-income communities, where innovative technologies and service-delivery

systems can be tailored to meet the needs of poor households. Similarly, considerable research suggests that reaching the poorest of households with water
supply and sanitation services can be facilitated by the participation of social
intermediation professionals.4
Capacity building is also essential in the area of gender-sensitive programming and policymaking. Because of differences in production, labor, responsibilities, and resources, women and men have different interests in, and derive
different benets from, the availability, use, and management of water. Women,
for instance, generally prioritize water for domestic uses such as drinking and
washing, whereas men may focus on irrigation. As a result, they often have
different criteria to evaluate the adequacy, equity, timeliness, convenience, and
quality of various interventions. Without a thorough gender analysis, planners
have a distorted picture of communities, natural resource uses, households, and
water users. Understanding the differences between womens and mens roles
(who does what work, who makes which decisions, who uses water for what,
who controls which resources, who is responsible for the different family obligations) is part of a good analysis and can contribute to more effective initiatives.
Capacity is enhanced through adherence to the principle of management
at the lowest appropriate level, expressed through mechanisms such as devolution of responsibility to local governments and communities, backed by technical assistance for appropriate capacity building and funding. However, lack
of nancial and managerial authority and capacity can be particularly problematic when responsibility for water supply and sanitation service delivery is
decentralized to local administrations. From planning and conict resolution
to revenue management and accounting, local governments often need considerable strengthening before they are able to administer services in an effective
and sustainable manner. Devolution of responsibility to local levels that are
not accompanied by devolution of nancial authority often leads to paralysis
of sector performance. Decentralization programs also inherently prejudice
households living in areas of weakest administration, which are typically the
rural poor. Moreover, the nancial difculties of the water and sanitation sector often make it difcult to attract and retain good engineers, managers, and
social intermediation professionalsparticularly in locations outside large
urban areas. Lastly, when responsibility is decentralized to communities without a sound system of regulation and oversight, communities can sometimes
compete among themselves for scarce water supplies in ways that can lead to
economic inefciencies; thus decentralization also needs to be accompanied by
effective regulatory and oversight mechanisms, as well as be embedded in an
overall system for management of water resources.
With respect to households, capacity building often requires little more
than tapping into the skills and endowments that already exist among community members. In some cases, improving access to information can go a
66
Part 1
It is also
important to
strengthen
capacity for
monitoring
long way toward making households aware of their rights and their options for
obtaining improved water supply and sanitation services. Alternatively, forming or supporting civic organizations can be a way of developing community
capabilities for organizing, planning, and even implementing local water and
sanitation projects.5 In other cases, partnership with local and international
nongovernmental organizations (NGOs) would be the feasible option.
Capacity building is often thought to pertain only to emergent institutions, such as local governments receiving authority for water and sanitation
planning in a decentralizing country. In such a situation, however, the role
of central government is also changing, and national institutions often need
strengthening in new and unfamiliar capacities. National and provincial agencies, for example, may need assistance in shifting from design and construction
to contracting, procurement, and oversight. It is also important to strengthen
capacity for monitoring of sustainable access to water supply and sanitation
services at the national level.
Incentives
Capacity building can provide individuals and institutions with the tools and
skills to improve water supply and sanitation services, but not necessarily with
the motivation to do so. From the household to the international level, current
incentive structures often work against extension of water supply and sanitation services to the poorest, as well as against the long-term sustainability of
installed infrastructure.
In urban areas, for example, service providers may either be prohibited
from installing trunk infrastructure, or may be reluctant to do so, in communities with insecure land tenure. Not only are households without a title denied
access to network services, but they often cannot obtain titles without evidence
of long-term residencysuch as bill payment receipts from the water supply
and sanitation agency. Families without titles are also reluctant to invest in private, individual water supply and sanitation facilities such as wells and latrines,
given that they feel vulnerable to clearance actions by government.
From the perspective of service providers, assignments to projects beneting low-income communities are viewed with disappointment by many agency
staff. Not only do they place employees in less attractive work environments
(urban slums or rural areas), but they also tend to emphasize simple technologies that are viewed as posing few interesting technical challenges. Even
where improved services are installed, service providers often view low-income
communities as having limited revenue potential, which in turn can engender inadequate maintenance and high rates of failure of systems serving poor
households.
The ribbon-cutting culture of water and sanitation agencies the world
overin which rapid progress toward construction objectives is prioritized over
virtually all other activitieshas also been well documented. This attitude is the
Chapter 5
Accountability
is needed
to impel
individuals
and
institutions
in the right
direction
67
consequence of demands placed on agency staff by elected and unelected leaders,

who themselves are under pressure to deliver new construction projects to constituents. As a result, human and nancial resources are allocated disproportionately to construction rather than operation and maintenance, thus placing the
sustainability of installed infrastructure at great risk. In addition, professional
status becomes increasingly associated with large-scale design, the latest technologies, and construction activities. Promotions (and elections) may easily be
decided on the basis of extending a new water or sewer line; they are rarely inuenced by the fact that an existing water supply and sanitation system continues
to function well, or by a reduction in unaccounted-for water. This description of
professional incentives favoring new, large construction projects is also relevant
to donor agencies and multilateral development banks. In most organizations,
incentives are largely structured around the number and value of new projects,
rather than around the performance or sustainability of existing initiatives.
Accountability
Accountability is a special form of incentive. It is needed to impel individuals
and institutions in the right direction. Accountability mechanisms are essential
to hold government, service providers, and international institutions responsible for their action (or inaction) in improving sustainable access to water supply and sanitation services. Accountability implies both a measurable standard
of performance and a consequence for the failure to meet that standard. In a
competitive market, for example, a service provider who does not meet his or
her obligations to customers will suffer the consequence of losing business to
a competitor.
Given the limited scope for competition in water supply and sanitation service delivery, this market approach to accountability has limited applicability for
reaching target 10. One promising alternative strategy for improving accountability in water supply and sanitation service delivery is the decentralization of
planning and budgeting to local institutions. Decentralization offers the potential of increasing the inuence of communities and households over decisionmaking, through elections, social norms, and expressions of public opinion.
Decentralization can also improve accountability by separating policymaking
for example, for tariff setting) from service delivery activities. It is important to
note, however, that decentralization will have limited (or even negative) effects
if it is implemented in areas with inadequate capacity or if central government
does not maintain an active role in oversight by retaining control over certain
key functions, such as setting standards or redistributing resources to subsidize
service for the poor. One method of capturing the gain from decentralization is
through benchmarking of performance of service providers.
At the international level, the global institutional structure for supporting
water and sanitation issues is still not fully aligned with the Millennium Development Goal initiative. In particular, the accountability of the international
68
Part 1
The regulator
should have
a clearly
dened
mandate and
authority,
with
independent
funding
community could be substantially enhanced by the development of an effective system to assess and report regularly on what actions have been taken to
meet the goals and on the extent to which those actions have advanced progress
toward achieving the goals.
Regulatory system
Absence of a sound regulatory system and a strong regulator are generally held
to be constraints to good performance by public as well as private sector operators. The overall aim of regulation is to ensure that such sector goals as target
10 are reached, condence is established in the sector to attract private investor participation in nancing and service delivery, and that the interests of
both users and service providers are protected. A key complement, especially
where private sector participation is involved, is establishment of instruments
for arbitration. Good regulation is critical in public sector systems and particularly so in decentralized administrations.
The regulator should have a clearly dened mandate and authority, with
an independent source of funding. The primary responsibility of the regulator
should be to supervise operators, both public and private. Two types of regulation are necessary: quality regulation and economic regulation.
Quality regulation is used to track the quality and efciency of service
providers. It entails monitoring service operators to determine whether they
are meeting their contractual obligations to provide access to service coverage
and quality of service within the authorized tariffs, rather than merely providing access to dysfunctional infrastructure. To do so effectively, the regulator
should dene goals and performance standards so that actual service delivery
can be compared with them. In addition, he or she should dene the tariff
policy, provide information on required investment to meet stated goals, and
advise on funding sources to meet investment goals.
The minimum standards to be followed should be dened by central government, leaving regional governments to dene local standards, provided that
they are not lower than the national standards. Best practice suggests that
both public and private service providers should operate under the specied
targets, with rewards for exceeding such targets and sanctions for failure to
meet them in terms of costs and timeliness. Quality regulation is also needed
to monitor the implementation of reform measures and the ow of resources
into the sector.
Economic regulation is required for tariff-setting on the basis of agreed
upon objective criteria. It seeks to ensure that the interests of both operators
and users are protected. A key principle is to ensure that consumers are not
made to pay for the inefciencies of service providers. Competition between
operators and benchmarking are considered to be powerful instruments in
economic regulation. Competition helps to improve performance and reduce
costs, hence reducing charges and improving affordability. Benchmarking
Chapter 5
Central
government
should
provide
incentives
for good
reporting
Financial constraints
Poverty is a principal impediment to increasing access to services, from the

household to the national level. Within communities, some households simply cannot afford the costs of improved services without assistance from other
families or from the state. Compared with the rich, many poor households pay a
much higher proportion of their incomes toward their daily needs for water supply and sanitation services from informal private providers. Such households do
not have access to credit markets; yet without such access, they cannot nance
expansion of service to their communities or the costs of a piped connection,
neither can they afford the cost of installation of private wells or latrines.
At the national level, too, it is common wisdom that wealth is positively
associated with access to water supply and sanitation services at virtually every
level of analysis (gure 5.1). Middle- and upper-income countries enjoy higher
service coverage rates than lower-income countries, just as wealthier households within a given community are more likely to have improved services
as compared with their poorer neighbors. (It is interesting to note, however,
the large variation around the general trend; some low-income countries have
given political priority to expanding services to their populations and thus
have higher rates of coverage than income alone would predict.) Expanding
access to water supply and sanitation requires moneywhether from national
Note: R2 = 0.77.
Source: WHO/UNICEF JMP
2000; World Bank 2004.
Per capita national

income and access to
water supply in selected
countries, 2000
69
yields information that can be used for performance comparison and tariff setting. Its outputs can give signals that can help to determine whether programs
are on track to achieve targets. The information it provides can give signals
that can be used for making mid-course adjustments to technical strategies in
order to improve sector performance. In view of the importance of such information, central government should provide incentives to local governments
and operators for good reporting.
Figure 5.1
Access to water
supply rises as
national income rises
70
Part 1
and subnational government tax revenues, user charges, cross-subsidies from

users who can afford to pay, private-sector investment, or ofcial development
assistance.
In terms of water supply, about 5 of 10 people have household connections
(tapped water into their house or yard); 3 of 10 used another improved water
source, such as a public standpipe; and 2 of 10 used unimproved sources. As
can be seen in gure 5.2, having these household connections, the highest level
of service, is correlated closely with income. Similarly, as can be seen in gure
5.3, the level of sanitation service also rises in tandem with income.
Funds must be available not simply to construct new water supply and
sanitation facilities, but also to support their operation and maintenance over
the long term. The many defunct piped networks, handpumps, and latrines
throughout the developing world are due in part to inadequate resources for
The richest are twice

as likely to use
drinking water from
an improved source
as the poorest
Average share of
population using improved
drinking water in 20
developing countries, by
wealth quintile
Figure 5.2
Source: Data from selected

surveys for 20 developing
countries. Adapted from
Figure 5.3
Average share of
population using
improved sanitation in 20
developing countries, by
wealth quintile
Source: Data from selected

surveys for 20 developing
countries. Adapted from
The richest are four

times more likely
to use improved
sanitation than
the poorest
Chapter 5
Realizing
these
benets
requires the
willingness
to plan,
manage, and
implement
effective
maintenance
71
proper maintenance. They are powerful reminders that, without this concern
for nancial sustainability, investments made in pursuit of target 10 will likely
yield only temporary benets. Indeed, experience suggests that the payoffs
to effective preventive maintenance and savings in terms of lower operating
costs, reduced adverse external impacts, and extended infrastructure life are
very substantial, and are generally underestimated by cuts in budgets intended
to meet specic scal targets. Realizing these benets, however, requires the
capacity and willingness to plan, manage, and implement effective maintenance. It also obliges a commitment to ensuring the reliable ow of funds for
nancing maintenance in a timely manner.
In discussing nancial constraints, a distinction should be made between
the absolute lack of resources for expanding water supply and sanitation coverage, and the need to redistribute potentially sufcient existing resources, so
that target 10 can be met. In some countries, sufcient nancial resources
exist to provide universal coverage, but their concentration among wealthier
households leaves a substantial proportion unserved.
Sizable gains in coverage can result from policy and institutional arrangements that encourage the redistribution of resources; they can also result from
loan nancing facilities that can also help households and communities to express
latent demand for services. In other countries, however, pervasive poverty creates
binding nancial constraints to coverage expansion. Here the challenges are to
mobilize the necessary resources from the international community, while also
working to ensure that budgetary processes, policies, and institutional arrangements within countries give priority to investment in basic water supply and
sanitation services for the poor. A second challenge is the recognition that the
poor cannot be expected to bear the full cost of improved access to water and
sanitation. Yet governments as well as donors often direct their resources not to
poor communities and countries where the needs for access are the greatest, but
rather to areas where there is political capture by politicians or where the criteria
for donor success, such as reforms, are in place.
Many towns and municipalities in developing countries are constrained by
a lack of access to loan-nancing facilities. Because of their limited revenues
from user fees and taxes, these communities often rely on transfers from central government to nance construction of improved water supply and sanitation networks. Transfers, however, are subject to uctuations in the national
economic and political climate, thus undermining cities ability to undertake
long-term water and sanitation planning.
Many water and sanitation utilities are characterized by weak managerial
and nancial capacities. In many cases, political pressures prevent them from
charging service prices that would cover recurrent costs, even in communities
with the collective nancial capacity to cross-subsidize service for the poorest.
This, together with poor demand management and high levels of unaccountedfor water, often make it impossible for utilities to generate sufcient cash ows
72
Part 1
Overly
optimistic
expectations
from private
sector
investments
are another
constraint
for recurrent expenditures. As a result, their creditworthiness is weak, and they

are unable to attract investment for expansion. Indeed, many water and sanitation agencies have difculty funding proper operation and maintenance of
the systems they currently manage, much less expanding services to keep pace
with the rapid growth in their communities. Reliance on recurrent funding
from state or national government for operation and maintenance is even more
tenuous than that for construction. Thus, instead of moving toward nancial self-sufciency and universal coverage, agencies deliver subsidized service
largely to their communities wealthiest households that have more political or
social inuence. In other cases, nancial regulations require that revenues from
water supply are sent to national coffers and are prevented from being used
for water supply operations and maintenance. Where such revenues have been
ring-fenced for the exclusive use of the water supply agencies that collected
them, signicant improvements have resulted in performance.
Overly optimistic expectations from private sector investments are another
constraint. Some developing-country governments are reducing national
expenditures for water supply and sanitation with the expectation that the
investment gap will be lled by the private sector. Recent evidence suggests
that this attitude appears to be overly optimistic (gure 5.4). After peaking in
1997, external private nancial ows have decreased steadily during the past
several years.6 The features of investment in water and sanitation facilities
including its lumpiness, payback periods of 20 years or more, and political
difculty of charging cost-recovering tariffsmake it difcult to attract private investment. The frequency with which water and sanitation concessions
in both developing and industrialized countries have been postponed or cancelled over the past several years is evidence of how difcult it is to design and
implement successful private-sector involvement in water supply and sanitation
services. And private sector investment does not go to the areas of greatest need
(where coverage is lowest); it has been estimated that between 199097, less
Annual private investment

in infrastructure,
19902000
Source: World Bank data
on private participation in
infrastructure projects.
Figure 5.4
Private investment
in infrastructure
has fallen off in
recent years
Chapter 5
Weak local
nancial
markets
constitute
another
constraint
73
than 0.2 percent of all private sector investments in the water and sanitation
sector of developing countries went to Sub-Saharan Africa.7
This decline in private sector investment in water supply and sanitation for
developing countries has taken place against the backdrop of an ongoing and
heated debate about the appropriate roles for the private sector in this areaa
debate that has been polarized around conicting ideological positions and has
led to major conicts, especially around large-scale projects involving multinational companies. The cost of conict generated a stalemate of sorts amongst
stakeholders on how best to move forward with improving access to water
supply and sanitation, with obvious consequences for the attainment of target
10, especially in middle-income countries. While there are signs that dialogue
around private sector involvement has recently become less polarized and more
productive, still-greater constructive engagement around this issue is needed;
such engagement could be enhanced, for example, through an independent,
balanced multistakeholder assessment of the impacts of public and private sector participation that would glean lessons from past experiences and enhance
decisionmaking on service delivery options.
Weak local nancial markets constitute another constraint to the nancing of improved access to water supply and sanitation services. As a result, there
is a tendency to rely on nancing that is denominated in foreign currencies.
Yet revenues on which utilities and government would depend to repay such
loans are denominated in local currencies. Such reliance on external nancing
is constrained by several risks, such as devaluation and liquidity risks associated with the low cashows from utilities. The Report of the World Panel on
Financing Water Infrastructure provides a number of remedial measures, such
as special forms of international guarantees that can be used to address nancing problems (World Panel on Financing Water Infrastructure 2003). However, a lot depends upon action by governments and utilities to increase their
cash ows and strengthening their nancial and managerial capacities.
Trends in ofcial development assistance indicate that support for water supply and sanitation infrastructure is very modest, both in relation to support provided to other infrastructure sectors and in terms of what is necessary to meet
the Millennium Development Goals for water and sanitation. A recent report by
the Development Co-operation Directorate of the Organisation for Economic
Co-operation and Development shows that only 6 percent of total bilateral aid in
200102 went to the water sector and that only 16 percent of that water aid went
to countries where less than 60 percent of population has access to an improved
water source. Moreover, aid to water and sanitation is concentrated in certain
countries, with the 10 largest recipients receiving 53 percent of the total. Support tends to focus primarily on the provision of urban infrastructure to middleincome countries (OECD-DAC 2004); yet, the greatest needs are in rural areas.
Moreover, the prerequisite condition normally prescribed for ofcial development assistancethat for effective and accountable use of such aid, certain
74
Part 1
Provision
of safe and
reliable
services is
often more
technically
challenging
in poor
communities
reforms must be in placehas been a constraint to the countries most in need

for help in meeting target 10. While recognizing the importance of such reforms,
the task force believes that the alternative principle of pursuing reform and capacity strengthening simultaneously with investment, using the learning by doing
approach, is more likely to help the weakest countries to meet target 10.
One means to address the issues of inadequate nancial resources; poor
donor coordination; and shifting priorities to provide adequate, sustained
nancial and technical support for the achievement of the water and sanitation Goals would be through regional-level multilateral donor mechanisms.
Regional water and sanitation facilities could provide funds for both sector
investment and capacity building in the poorest countries. Just such a facilitythe African Water Facilityis at an advanced stage of development and
will be hosted within the African Development Bank. Some characteristics
of the African Water Facility provide useful pointers for similar facilities elsewhere, including being housed in a regional bank with UN Regional Ofce
support and liaison; access on a self-selection basis; and an approach that combines capacity building, reforms, and investments toward the achievement of
the Goals for water and sanitation. Another option is coordinated donor programs instead of project-based funding.
Technical challenges
One of the important lessons of the past several decades of international collaboration for expanding water supply and sanitation services has been that
nontechnical issues, such as nancing and institutions, are equally importantand often more importantexplanations for the persistent lack of
access among developing countries than are technical challenges. At the same
time, the pendulum should not swing so far as to neglect entirely the role of
technical considerations in expanding services. Indeed, the provision of safe
and reliable services is often more technically challenging in poor communities
than in rich ones. Extending services to a dispersed rural settlement or dense
urban community on marginal land, for example, is one of the tougher design
problems that a water and sanitation engineer can face.
Climatic factors can certainly shape a countrys ability to provide and
maintain water supply and sanitation services for its citizens. Many developing
countries in the tropics, for example, suffer alternately from oods that damage infrastructure and droughts during which water sources run dry. Whereas
inexpensive solutions are available in some cases (for example, rainwater harvesting), in others costly infrastructure is required in order to control droughts
and store water for the dry periods. Such physical constraints may hinder economic development in general and thus impede progress toward all the Millennium Development Goals.
Although the amounts of water required for increasing access to safe drinking water supply and sanitation are relatively minor in comparison with the
Chapter 5
Achieving
environmentally
acceptable
sanitation
solutions
is a major
technical
challenge
75
amounts required for agricultural uses, there are often situations in which the
physical availability of water resources on a sustainable basis (and access to
technologies suited to that environment) limits efforts to increase sustainable
access to water and sanitation. It is important to note, however, that in other
cases what is termed water scarcityat least as regards water for domestic
purposesis often the result of decisions at various levels to prioritize water
allocation to other uses and to expend limited budgetary resources on activities other than accessing, treating, and transporting water for household use.
It is also important to recognize that, although water and sanitation are often
seen principally as a challenge of capital investment, the provision of water
and sanitation services is an ongoing business that has to be understood and
managed as such if it is to achieve and sustain its goals. Where a water supply
system is poorly planned or poorly managed, the consequences often include
excessive loss of water through leakages and waste, as well as loss of the revenue needed to run it effectively through unmanaged consumer connections.
Finally, achieving environmentally acceptable sanitation solutions is a major
technical challenge, particularly in urban and periurban areasindeed, some
approaches may lead to a period of transitional environmental pollution, since
increasing access to sanitation under conditions of water stress means that there
will be more and more pollutants being disposed into less and less water.
In some instances, sustainable access to water may be limited by the physical availability of water itselfwhere countries or communities have an inadequate water supply at a reasonable distance either in terms of quantity or
quality (whether because of low rainfall, topography, hydrology, or geography)
or might face such constraints in the future, because of such factors as population increases or climate change. Sometimes, one or more particular challengessuch as arsenic contamination, salinity, guinea worm infestation, or
groundwater depletionneed to be overcome to ensure a safe drinking water
supply.
At a global level, the withdrawal of water supplies for domestic, industrial and livestock use is projected to increase by at least 50 percent by 2025.
According to the International Food Policy Research Institute and the International Water Management Institute (Rosegrant and others 2002), current
trends show a water crisis could occur, leading to a breakdown in domestic
water service for hundreds of millions of peoplemost signicantly in the
developing worldas well as devastating loss of wetlands, serious reductions
in food production, and skyrocketing food prices. If current trends worsen
even moderately, farmers will drive down water tables by extracting increasing
amounts of water to get sufcient supply for their crops, the institutes predict.
The accelerated pumping could cause key aquifers to fail after 2010 in northern China, northern and northwestern India, West Asia, and North Africa.
Although the greatest impact of such a worsening of water trends would be
in the area of food production and rural livelihoods (the IWMI/IFPRI report
76
Part 1
Any strategy
to achieve
the water and
sanitation
Goals must
take into
account
the costs
estimates a loss of food production equivalent to Indias entire annual cereal

crop or the combined annual harvest of Sub-Saharan Africa, North Africa, and
West Asia), the availability of water for drinking and sanitation purposes could
also be threatened in the most water-stressed areas. Such availability could also
be affected by climate change and increased climate variability, especially since
poor countries are the most vulnerable and have the least storage capacity to
be able to overcome the effects of climate variability and change and natural
disasters (UN/ISDR 2004).
Strategies to prevent this crisis scenarioprincipally investment in infrastructure to increase the supply of water for irrigation, domestic, and industrial
purposes; conservation of water and improved efciency of water use in existing
systems through water management and policy reform; and improvement of
crop productivity per unit of water and landextend beyond the narrow water
and sanitation sector and relate to the proper management of water resources as
a whole, as discussed in part 2. Nevertheless, they will be a necessary component of any strategy to increase sustainable access to water supply and sanitation
in areas in which the physical availability of water is a limiting factor.
The relative availability of water will of course have a strong impact on the
costs of increasing sustainable access to water and sanitation. Some estimates of
the costs involved in meeting the water and sanitation target appear to assume
that the water resource itself is free, and need to be adjusted to include not only
the costs of capture but the opportunity costs of the water itself. Many poor
women and men without access to water supply and sanitation live in places
where the shadow value of water is high, and the costs involved in increasing
access to water supply and sanitation will be greater in water-stressed environments, reecting waters scarcity value.
Thus, any strategy to achieve the water and sanitation Goals must take into
account the costs of meeting the Goals as differentiated by ecological settings.
To this end, a sound analysis of water resource availability and technological
options to address the particular challenges of water-stressed environments is
needed. Since conditions are enormously context specic, it would be necessary to segment the overall problem by distinguishing among different ecological conditionsfor example, coastal areas, alluvial river basins, drought-prone
regions, and small island statesand assessing the technological options for
increasing access to drinking water supplies required in each case.
Strategies to achieve the water and sanitation Goals must also take into
account that additional water supplies can be generated through demand management and reductions of water wastage, primarily in cities, through such
mechanisms as tariff structures and leak detection. But the potential value
of demand management approaches should take into account at least two
potential caveats. First, since water wasted through leakage may be reused, in
calculating the benets of reducing wastage, the additional cost of providing
access to people whose water supply currently depends on such leakages must
Chapter 5
Many
constraints
lie outside
the sector
77
be factored in. Second, higher levels of efciency can sometimes lead to higher
levels of risk. Experience in South Africa, for example, has led to some concern
that very high levels of water efciency lead to vulnerability to drought and
climate variability more generally.
Two nal points should be considered. The rst is that poorer countries and
communities, especially those located in water-stressed areas, must learn how to
live with perennial water scarcity and design their development around it. Most
cities in arid zones do not, for example, have limits on multistoried houses or on
water-consuming ushes. The second point is that groundwater protection is a
high priority in many water-stressed areas. Overexploitation of groundwater for
agricultural purposes increases the cost of water supply for drinking purposes,
which is further increased by the need for additional treatment.
Conclusion
One of the most striking implications of the previous sections is that many of
the constraints to improved access to water supply and sanitation services lie
outside the sector itself. The inadequate nancial allocations to water supply
and sanitation services in most developing countries are the result of budgetsetting processes in which water and sanitation are pitted against any number
Box 5.2
Overcoming
constraints and
increasing access:
the South African
experience
Source: World Bank 2002.
Although not reected as such in the Human Development Reports gures in 1994, 15.2
million (38 percent) of South Africas population of 40 million lacked access to basic water
supply (dened in South Africa as 25 liters of water per person per day within 200 meters
from home). In addition, just over 50 percent (20.5 million) lacked access to basic sanitation (dened as a ventilated improved pit latrine or its equivalent).
South Africa has used a combination of policy instruments and investments to expand
coverage quickly and dramatically in just eight years. Devolution of responsibility for water
supply and sanitation from the national level to the local government level using community-based approaches has been accompanied by policy reforms and an accompanying
legislative framework. A capital works program was launched, which has provided infrastructure to meet the needs of nearly 10 million rural people, and municipal programs
have extended services to their growing populations as well. Finally, the free basic water
supply program has provided water to some 27 million people as of July 1, 2002. South
Africa now expects that, within seven more years, all citizens will have access to basic
water supply.
Clearly, the experience of South Africa is not a model that can simply be transferred
to other settings, but it does provide insight into the challenges of attaining the Millennium Development Goals. At a recent international conference, Ronnie Kasrils, minister of
water affairs of South Africa, identied the three key factors that led to success in South
Africa as strong political leadership, a willingness to take action without having planned
every last detail, and adequate nancial resources. Jan Pronk emphasized the third point
(money, money, money) and added four additional how-to principles: setting clear
goals, organizing your tax base, focusing on water and sanitation, and involving local governments. These how-to principles are universally applicable.
78
Part 1
of competing claims for limited resources. Lack of responsiveness and accountability in water and sanitation service provision often stems from broader
civil-service legislation and the balance of power between central and local
government, both of which are established at the national level. Governments
that are committed to improving long-term access to water supply and sanitation services must, by extension, be prepared to make hard choices regarding
budget priorities, the devolution of powers to local administrations, and the
restructuring of incentives and accountability networks among the public, private, and civic sectors.
It is also important, however, to recognize that all of the constraints described
here are surmountable. Consider, for example, the case of South Africa (box
5.2) where access to water supply increased from 62 percent to 86 percent in
19942000. A systematic assessment of the impediments to extending water
supply and sanitation service coverage, however, enables the systematic development of strategies to address thema topic to which we turn in part 3.
Chapter 6
The special challenge of

meeting the sanitation target
Whereas the nancial, institutional, and technical constraints discussed in

chapter 5 pertain to expanding both water supply and sanitation services, in
practice, sanitation and hygiene receive substantially less attention, funding,
and priority than water supply in virtually every country the world over. It
should thus not be surprising that the WHO/UNICEF Joint Monitoring Programme (JMP) has recently warned that, [w]ithout a sharp acceleration in
the rate of progress, the world will miss the sanitation target by half a billion
people (WHO/UNICEF JMP 2004, p. 14). The international community is
dangerously off track from its goal of halving the proportion of people lacking
even basic sanitation services by 2015.
Perhaps the most daunting aspect of the sanitation target is simply the scale
of the problem. Today more than twice as many people lack access to basic
sanitation services as lack access to improved water supply. Meeting the Millennium Development target for sanitation requires bringing improved sanitation to 1.4 billion people over the next 10 years, or more than 383,000 people
every day. The cost of meeting this challenge is much higher than the cost of
meeting the challenge for water supply, not only because so many more people
must be served, but also because of the higher unit cost of sanitation infrastructure, especially for urban areas. Moreover, the socioeconomic and public
health costs of failure to meet the target are much higher and more widespread
for sanitation.
Recognizing the magnitude of the sanitation crisis in turn raises questions about how the global community allowed the problem to grow to such
immense proportions. That at least 2.6 billion people around the world are
forced to defecate in plastic bags, buckets, open pits, agricultural elds, and
public areas in their communities should generate a collective outcry for immediate, concerted efforts to expand access to improved sanitation facilities. Yet,
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Part 1
Some governments and

development
organizations
view sanitation as simply
a household
amenity
coverage rates in the developing world are barely keeping pace with population
growth; indeed, in some parts of Africa the percentage of households with
access to sanitation is actually declining. Why does sanitation command so
little attention from local and national governments and from the international
community?
A collective or an individual service?
The absence of sanitation from planning and policy dialogues can be traced in
part to the lack of a national-level institution with responsibility for sanitation
in the majority of countries in the developing world, as discussed more fully in
chapter 7. This institutional vacuum, however, is itself symptomatic of a broader
tension that exists regarding the allocation of responsibilities for improving
and managing sanitation services. Many of the public health benets stemming from improved sanitation are shared by the community at large, rather
than accruing principally to individual households (which, it could be argued,
is the case for improved water supply).1 As such, some have argued that community institutions, such as local, regional, and national governments, have
an interest inand an obligation towardallocating resources for sanitation
improvements. At the same time, households do benet from the increased
convenience, safety, privacy, and dignity of improved sanitation facilities in
their homes or neighborhoods. Some governments and development organizations, viewing sanitation in a restricted sense as simply a household amenity, have thus argued that it should be considered a household responsibility,
thereby discounting the public components and public benets of sanitation.
These different perspectives on the nature of responsibility for sanitation have
quite different implications for an appropriate institutional arrangement to
support service improvements.
Perceptions about the locus of responsibility for sanitation services have
also been shaped by the nature of the public and private components of water
versus sewer networks. In the case of urban water supply, for example, service
provision typically begins with installation of public infrastructure such as
water intake and treatment facilities, transmission lines, and main distribution
lines. Only once these assets are in place can households install connections to
the distribution network and make use of private internal plumbing systems.
Because all public components of the water system have been installed prior to
these individual private connections, the costs of the entire system are known
and can be allocated among consumers when setting service prices.
Historically, urban sewerage systems have been installed in a fashion similar
to that of urban water supply. Infrastructure development starts with the trunk
sewerage system and sewage treatment facilities, followed by the sewer network in each community. Once these public components have been installed,
residents can connect their homes to the sewer network. In many developing
countries, this approach has been markedly less successful for sanitation than
Chapter 6
Gender
inequality
is one
explanation
for low
effective
demand for
sanitation
The special challenge of meeting the sanitation target
81
for water supply. Sewer systems installed using this approach have often been
highly underutilized (as in Accra, Ghana) or have not been used at all (as in
Bombay, India). In other cases, plans to install citywide sewer systems are simply never implemented because of their prohibitive cost. An alternative approach
for expanding sanitation services in developing countries is clearly required.
The nature of demand for improved sanitation
Underlying these very different experiences with improved water supply versus
sanitation are differences in the nature of demand for the two services. Considerable research has documented, even among very poor households, higherthan-expected effective demand for improved water supply (dened as willingness and ability to pay for a service at a particular price). Effective demand for
improved sanitation, by contrast, is regularly found to be less than the cost of
its provision. This is so both for private demand and for public demand for the
public component of sanitation.
Many observers have suggested that low demand for sanitation is simply
the result of communities poor understanding of the links between sanitation,
hygiene, and health. In some cases this is true; often, however, households with
limited resources have simply pursued other investments in a rational prioritysetting process. In situations where both water supply and sanitation services
are scarce or of poor quality, demand for improved access to water almost
always outstrips demand for sanitation. The benets of the former are immediate and perceptible, and they accrue to a household irrespective of whether
other households also invest in improved services. By contrast, the benets of
sanitation are generally less immediate and obvious to the household, have
signicant public-goods characteristics (improved health for the community
as a whole), and may not materialize unless other households also acta factor
over which a given household may have little inuence.
Another explanation for the low effective demand for sanitation is gender
inequality. As discussed in chapter 2, women tend to place a higher value on
household toilets than do men for a number of reasons, among them privacy, cultural norms, care-giving responsibilities, and the risk of sexual harassment and
assault (box 6.1). Yet the limited political and personal power of women in many
developing countries means that some of sanitations strongest advocates are virtually absent from decisionmaking and priority-setting processes. When women
have little control over household expenditures, for instance, demand as gauged
by willingness to pay will not capture the true extent of household or community
demand for sanitation. In addition, the unique sanitation needs of women and
girls (for example, during menstruation and during and after pregnancy) receive
little recognition when discussions about sanitation and hygiene occur.
A mismatch between demand for improved sanitation and the type of
services provided is often implicated in cases of unused or underused sanitation infrastructure, such as in Accra and Bombay. At the heart of strategies to
82
Part 1
Box 6.1
Unheard voices
of women
I gave birth to my children while I was living in the same jhuggi (slum). After giving birth to
the child I do not eat food for two days and so there is no need to go to a latrine. But after
two days I go to the same place in open to defecate. When I go out to defecate my elder
children do baby sitting for the younger ones but there are times when the babies are left
alone in the jhuggi with no one to take care of them.
Miradevi, age 35, Sanjay Amar Colony, an urban slum in Delhi, India.
I go out in the open to defecate. Due to the continuous stare of men, I have to get up
again and again in between the process of defecation.
Babita, age 27, Sanjay Amar Colony.
achieve the Millennium Development target for sanitation, then, is the recognition that institutional, nancial, and technical supports must be focused
principally on understanding and responding to the felt needs, preferences,
beliefs, priorities, and constraints of households and communities regarding improved servicesas well as being sensitive to the gender dimension of
expressed demand. It is increasingly evident that people are willing to pay for
things that matter to them, including sanitation.
Unfortunately, little is known about the best means of promoting demand
for improved sanitation facilities. One important insight from research into
sanitation preferences is that, among the reasons that people invest in improved
services, health does not gure particularly prominently. More frequently,
households cite the convenience, privacy, dignity, safety, community status, or
reduction of odors and insects that improved facilities afford them. It is thus
critical to understand and exploit the right levers to motivate individuals and
communities to act. Treating access to basic sanitation as both a right and a
shared responsibility of all households in a given community may have greater
impact on attitudes and behaviors than traditional appeals only to individuallevel concerns about health.2
It is also instructive to consider how industrial countries have approached
this challenge of low effective demand for improved sanitation among households that they, too, once faced. In general, public infrastructure components
have been highly subsidized by governments of industrialized countries, reecting an understanding that the public health benets of sanitation generate
substantial positive externalities that merit public investment. In Britain, for
example, urban authorities borrowed more than 7.7 million for sewerage
works during the period 188091. Eventually the public provision of sanitation
became an uncontroversial and indeed, expected, part of life (Chaplin 1999).
Similarly, for many municipalities in the United States, public nancing of
sanitation infrastructure was seen as the only option for ensuring investment
adequate to protect public health. In nineteenth-century Boston, for example,
lower-than-expected connection rates among households to the citys new
Chapter 6
Progress in
sanitation
requires
that public
agencies
broaden their
traditional
role
83
water and sewer network prompted the city to cover the cost of service pipes
for all unconnected households. In 1850, an inuential state sanitary survey
concluded that government must accept responsibility for nancing public
sanitation infrastructure because, left to their own devices, a large proportion of Massachusetts residents would be unable or unwilling to take on personal responsibility to conduct their lives in accord with recommended sanitary principles (Rosenkrantz 1972 as quoted in Bartlett 2003). Until recently,
grants of up to 70 percent or more were provided for innovative sanitation
technologies in the United States.
Today, of course, scientic evidence and public awareness of the links
between improved sanitation, hygiene, and health is much stronger than in
nineteenth-century Britain and America. Nevertheless, households lacking
access to improved services often still need support to appreciate fully the
health and economic benets of sanitation and hygiene. Governments can
sponsor public education campaigns that identify the central role that sanitation and hygiene play in controlling cholera and other diarrheal diseases,
thereby encouraging such safer personal habits as hand washing, and increased
household investment in sanitation. At the same time, governments must
accept responsibility for ensuring the provision of the public components of
sanitation infrastructure and services, investments that underpin public health
and environmental objectives and for which effective demand among households will invariably be low.
Reorienting public institutions for sanitation service delivery
As the emphasis on strategies to expand access to sanitation shifts toward

inuencing household and collective action at the neighborhood level, governments at all levels are confronted with new challenges. Progress in sanitation
requires that public agencies broaden their traditional service-provision role
to include encouraging and supporting desired household and community
actions. Most public agencies are unfamiliar with or ill-suited for this role.
Water and sanitation service agencies are typically modeled after utilities in
industrial countries, and as such are organized around the goals of maximizing operational efciency for public sanitation components (trunk sewers and
treatment plants). Indeed, most water supply and sanitation agencies in industrial nations have very little direct interaction with hygienic behavior of households at all. Hygienic household behaviors are entrenched or are promoted
through other channels, and the infrastructure that underpins them (reliable,
abundant piped water and household toilet facilities) is universally available. In
many developing countries, of course, these conditions do not apply. Institutional arrangements are thus needed, over and above those needed for normal
utility functions, to target household behaviors and collective decisionmaking
in communities, promoting solidarity, social capital, and the kind of hygienic
culture that affords value to improved sanitation facilities.
84
Part 1
Engaging
communitylevel
institutions
should be at
the center
of efforts
World Development Report 2004: Making Services Work for Poor People notes
that in conventional service delivery arrangements, the same agency is often
responsible for both service delivery and oversight, while the citizen/consumer
is a passive recipient rather than an active participant (World Bank 2003).
As discussed above, World Development Report 2004 notes that the prevailing
supply-driven approach to sanitation has led to the installation of infrastructure that communities did not want or could not afford. Over time, households that were never reached with services or that obtained services that failed
or did not meet their needs have been forced to turn to self-provision or to
unregulated third-party providers. Recent research in India indicates that as
many as 8 percent of rural households across the country invested their own
money and used small private providers to construct latrines (Kolsky and others 2000). Self-provision accounts for about 1 million privately installed septic
tanks in Manila and in Jakarta. Research in Africa conrms that the role of
the small-scale private sector in sanitation provision is signicant (Collignon
and Vezina 2000). These ndings are further supported by data from the JMP:
between 1990 and 2000, the increased number of people served with sanitation reported by the JMP was much larger than the expected impacts of the
public investment that occurred during this period
Reorienting public institutions to broaden their focus toward an emphasis
on inuencing citizen/consumer behavior, as well as toward engaging community-level institutions in planning appropriate interventions, should be at the
center of efforts to expand household access to private sanitation. For many
countries, such a shift in strategy has major implications for institutions both
within and outside the sector. For example, the prevailing custom of linking
sanitation exclusively with water supply in policy and planning should be reconsidered. Greater progress in expanding access to basic sanitation may result from
also forging strong linkages with other services that engage households in a
more direct and continuous manner, such as health, education, agricultural
extension, and rural development. The role of local government, community
organizations, and small-scale private providers should grow for householdand community-level services in parallel with the growth of centralized service
delivery agencies to provide public sanitation services to complement private
services.3
Where all three aspects of sanitation (the household level, community/
neighborhood level, and the public level) remain conned within a traditional
utility organization, partnerships with other services that engage households
in a more direct and continuous manner can help infuse the agency with the
new skills needed to target household and community decision-making more
effectively. A study soon to be published by the Water Supply and Sanitation
Coordinating Council (WSSCC and others forthcoming) notes that the needed
human resources can be found in a wide variety of locations, including:
Chapter 6
The ultimate
goal should
be having
the right
skills and
mix of staff
85
Government agencies: health, education, environmental, rural development, and urban planning departments, as well as local government.
Civil society: nongovernmental organizations, community-based groups,
self-help groups, micronance organizations, households themselves.
Private sector: small-scale private providers, personal hygiene product
companies, building contractors, advertising agencies, and the media.
Where the number of unserved in a given area is considerable, agencies
might consider employing a franchising approach to partnership arrangements in sanitation. In such arrangements, agencies contract with one or more
large civic or private organizations that, in turn, subcontract other smaller
organizations that operate at the community level. The principal organizations
are responsible for training their subcontractors, as well as for ensuring that
performance is uniform and of high quality. For the public agency, the need
for only a small number of contracts in the franchising model reduces administration and monitoring costs. For unserved communities, this arrangement
offers a dramatic increase in locally based, accountable organizations providing improved sanitation services.
Clearly the types of efforts needed to effect change in the prevailing sanitation paradigm require considerable resources and energy. Equally important is
the recognition that powerful stakeholders have vested interests in seeing that
the status quo for sanitation service provision is maintained. This observation is certainly not unique to developing countries. More than 140 years ago,
middle-class Victorians in Britain failed to grasp the urgent need to increase
access to basic sanitation for everyone; they felt that public expenditure on
such services would be wasted and, worse, would divert scarce public resources
from more important needs.
The same concerns exist today in countries seeking to meet the Millennium Development Goals and are compounded by the institutional barriers
of dismantling organizations that are structured to deliver the wrong sorts of
services. The costs of such radical institutional change may simply be too high
for some politicians. As a result, some countries may prefer to take a gradual
approach to changing the way services are offered, perhaps by experimenting
in geographically dened pilot areas or by shifting staff on temporary reassignments. The ultimate goal should be having the right skills and mix of staff
working at the right locations.
Changing roles for government
Public water supply and sanitation agencies are thus being asked to pull back
from many of the service-provision activities they are comfortable with, as well
as to develop new capacities or partnerships for activities that promote and
respond to demand for improved sanitation at the household and community
levels. For their part, national governments should assume responsibility for the
broad overall strategic planning for sanitation services and must also strengthen
86
Part 1
Shifts in the
way public
resources
are used for
sanitation are
also in order
and recommit to their role as a regulator of services, promoting innovation and

expansion of access while also protecting both citizens and the environment.
Shifts in the way public resources are used for sanitation are also in order.
The case can clearly be made for public investment in collective assets, such
as trunk sewers and wastewater treatment plants, as well as sanitary facilities
in schools; as noted earlier, however, at the household and community levels,
evidence suggests that the most effective use of public funds may be in powerful marketing and promotion of sanitation and hygiene. Supporting ancillary services such as micronance may also help households and communities
to express latent demand for service improvements, as well as to support an
emerging market of small-scale service providers who can respond to varied
and changing demand at the community and household levels.4
This is not to say that there is no role for targeted subsidies to increase
access to sanitation by poor households. As noted previously, sanitation and
hygienic behaviors have signicant positive public health impacts, which justify public investment. (Not to mention the strong human rights and human
values arguments described in chapter 2.) At the same time, the implementation of subsidy programs for sanitationparticularly latrine construction programs in rural areashave focused largely on funding of hardware with little
or no attention paid to the critical issues of community members felt needs,
priorities, and beliefs. As a result, many of these programs fail because they do
not address a principal constraint for sanitation improvement; low expressed
demand, not affordability, was at the heart of the problem. In other programs,
households (particularly the poorest) are unable to make up the funding gap
between the subsidy provided and the cost of the standard facility offered. In
addition, problems with technology choices, including too few options, inappropriate designs, or poor construction, undermine households condence in
the program and their willingness to risk investing scarce family resources.
It is not surprising that a discussion of governments role in improving
access comes back to the same themes that underpin the discussion of traditional sanitation providers. Without an emphasis on policies and planning
strategies that embrace and respond to local knowledge and priorities, progress
in expanding improved sanitation services in the developing world will continue to be slow. Governments can encourage these shifts in the sanitation
sector by:
Commissioning (and funding) research into communities priorities,
needs, preferences, and practices, as well as into factors that motivate
behavior change.
Funding an effective national hygiene promotion program.
Funding an effective national sanitation marketing program.
Supporting policies that spur expansion of services, such as the provision of microcredit and support for small-scale, independent service
providers.
Chapter 6
A full
complement
of
technologies
is now
available
87
Promoting and nancing innovations in low-cost sanitation technologies, especially those appropriate for congested settlements.
Requiring and nancing hygiene curricula and separate sanitary facilities for girls and boys in schools.
Targeting public funds toward elements of sanitation systems for which
public benet is greater than the private benet (for example, trunk
infrastructure, shared facilities, environmental infrastructure, and
household facilities for the small proportion of households whose effective demand is not high enough to obtain hygienic sanitary facilities).5
Supporting the development of community-based franchising approaches
that are exible, sustainable, and replicable on a large scale.
New technologies or better use of existing technologies?
Clearly innovation is needed in the institutional, policy, and nancial arenas to

meet the Millennium Development Goal for sanitation. With respect to technical innovation, most experts agree that a full complement of technologies is
now available for the provision of safe and reliable sanitation services in almost
any setting.6 For many countries, however, sanitation planners are unable to
take advantage of many of these technical options. They are constrained by
policies, planning regulations, technical norms and standards, and conventions that limit the range of sanitation options.
Technical conventions and standards are usually developed for good reasons, and often when they are promulgated, they embody the technological
state of the art. Often, however, standards constrain innovation and eventually hinder progress toward access targets. This is particularly true for sanitation
norms that have been adopted from other countries or regions without sufcient
adaptation for local conditions. Furthermore, written norms tend to reect an
idealized solution in which a uniformly high level of service is provided. While
desirable in the longer term, such standards may be prohibitively costly for
immediate use, may no longer be necessary as a result of technological advances,
or may be irrelevant for local circumstances (as in the case of norms that do not
apply to highly congested urban areas or dispersed rural districts).
Innovation and exibility with technical standards will allow developing countries to expand sustainable access to sanitation more rapidly and cost
effectively. Technical designs should also reect the new emphasis on local
decisionmaking that is increasingly infusing planning and policy work in the
sector. For example, allowing households, neighborhoods, and communities to
choose from among a range of technological options based on their preferences
and willingness to payrather than requiring a uniform standard across an
entire city or regionwould result in a self-selected technological mix, accelerate progress, and bring improved services to more households in the short
term. Decentralizing urban sanitation planning allows phased implementation
of affordable investments within different zones of a city, thereby overcom-
88
Part 1
Changing
technical
norms and
standards for
sanitation
services
can be very
challenging
ing the constraint of the lumpiness of investments, especially in large urban

areas. Connecting public sanitation infrastructure to neighborhood-level
infrastructurerather than to household-level infrastructure, as is done in the
developed countriesallows for more rapid and cost-effective progress, and
also helps create pressure for households to join in collective action to improve
sanitation within their communities.
Changing technical norms and standards for sanitation services can, however, be very challenging. Entrenched resistance may arise from technocrats
who have a stake in preserving the status quo and whose training is rooted in
accepted practices. Organizations whose culture does not encourage or value
innovation may also resist such changes. Elected ofcials may be reluctant to
champion the relaxing of norms, lest they be perceived as advocating substandard sanitation services to the public. It is clear, however, that many governments cannot afford waterborne, sewered sanitation for all, and that topshelf technologies are not a cost-effective option for many of the communities
and households that currently lack access. This is an area in which the international community clearly has an important role to play. Not only can international organizations support (preferably indigenous) research, development,
and piloting of appropriate sanitation technologies, they should also undertake parallel policy advice and efforts to encourage the adoption of appropriate
standards in countries seeking to expand sanitation coverage to the unserved.
Alternative planning approaches for urban sanitation
Considering the difculty that planners have had with traditional, supply-oriented approaches to the installation of sanitation infrastructure, a number of
innovative alternatives have emerged that deserve attention in the Millennium
Development context. As one example, experiments with reversing the service
provision chain for urban sewerage have occurred in several developing countries. Instead of investing rst in wastewater treatment facilities and trunk sewers, priority was given to providing an initial minimal level of sanitation services to households, as well as some mechanism for removing wastes from the
community. For network systems, initial investments thus include some form of
hygienic private or shared toilet facility for households, along with a feeder sewerage system that carries wastes safely away from the neighborhood. For on-site
systems such as those using septic tanks, emphasis should be put on the installation of two parallel systems of soil absorption that should be used one at a time
and interchanged on an annual basis. They should also be supported by a eet
of septic-tank-emptying trucks, together with public facilities for septage treatment. Similarly, facilities should be provided for pit-emptying services for on-site
facilities, such as ventilated improved pit latrines and pour-ush latrines.
Because these household- and community-level sanitation services are
those whose benets are most readily perceived by households, they are also
the services for which households tend to be most willing to pay. Hence, it
Chapter 6
Experiments
with reversing
the service
provision
chain for
urban
sewerage
have occurred
in several
developing
countries
should be possible to treat household and neighborhood sanitation infrastructure and services as private facilities exclusive to the communities concerned.
Many cities in the developing world, such as Manila and Jakarta, have achieved
this minimal level of sanitation service at the household level for millions of
people. In most cases, however, such investments have not been followed by the
development of community- or public-level sanitation infrastructure, such as
feeder and trunk sewerage systems, to convey the household-level wastes away
from the community for treatment and safe disposal. As a result, septic tank
and feeder network efuents regularly ow into open streams and drainage
channels, creating public health risks, environmental damage, and unpleasant
living conditions. Even in the many cities of Latin America where relatively
complete feeder and trunk sewerage systems have been constructed, only about
one third of them have sewage treatment plants. Public health concerns are
thus generally addressed in the immediate neighborhoods, but environmental
damage from untreated waste continues unabated, often affecting the poor
who live downstream.
The term sanitation ladder is often used to describe these types of planning approaches that seek to make progress in a gradual way (gure 6.1).
Starting with immediate, household-level access to sanitation facilities, then
moving gradually toward collective infrastructure components, such as feeder
sewerage at the community or neighborhood levels, and eventually to trunk
sewers and treatment plants. This approach has clearly helped to make progress in cities that would otherwise have taken much longer to move toward the
top of the sanitation ladder. At the same time, achieving localized sanitation
improvements can actually generate environmental pollution and, at times,
health risks for downstream neighboring communities. How should such
Figure 6.1
Urban water and
sanitation services
are much more
expensive than
simpler rural services
Note: Estimated costs

include overhead charges
of 15 percent, as well as
operation and maintenance
costs. Costs in dollars per
person are not to scale.
Source: van de Guchte,
and Vandeweerd 2004.
89
90
Part 1
An important
rst step is to
clearly dene
responsibilities for
household,
community,
and public
provision
tradeoffsbetween the short and long term and between access to basic sanitation services (on one hand) and health- and environment-related benets (on
the other)be managed? How long a transitional period should be tolerated
between the attainment of basic sanitation for households and concomitant
production of negative environmental externalities? These are difcult policy
questions with which countries and their international development partners
will continue to grapple.
Breaking the full set of sanitation objectives into manageable stepsfrom
the safe collection, storage, and disposal or reuse of human excreta to the
treatment and disposal, reuse, or recycling of sewage efuents and hazardous wastecan help create opportunities for progress where the entire challenge seems overwhelming. In many cases, more progress can be made by rst
focusing on a few solvable problems rather than by waiting until adequate
resources and support are available for a full-scale intervention. Indeed, this
phased approach was pursued in many of the countries that now enjoy universal access to sanitation services. This is not to say that the approaches of
100 years ago should be followed blindly. Much more is known today about,
for example, environmental protection, which should generate more effective
and sustainable solutions. Yet, while it may be desirable to develop a holistic
strategic plan for improving sanitation, practicality and resources may dictate
that a phased or stepped approach must be taken for implementation of such
strategic plans. An important rst step to addressing this problem is to clearly
dene responsibilities for household, community, and public level sanitation
service provision.
Alternative planning approaches for rural sanitation
The scale problems in sanitation are even greater in rural areas, where the
absolute poor in low-income countries most off-track in reaching the sanitation targets tend to be concentrated. The majority of the rural population lives
in sometimes remote, dispersed settlements; others, in countries such as Egypt,
live in very high density settlements. The number of such communities and
the wide areas over which they tend to be distributed makes reaching them
a formidable task. What is required is a signicantly scaled-up approach that
can be applied simultaneously over a wide areaan approach that centers on
community mobilization and actions that support and encourage such mobilization. That kind of approach supports community members in their efforts
to discuss sanitation practices with households that are within their boundaries and to devise locally appropriate and affordable strategies for improving
services. Where necessary, government, civic, and external organizations may
support these community-planning processes by providing information, technical support, or even nancial support or loans for facility construction.
One such approach is the franchise approach described earlier. It is being
tried in community-based sanitation programs in Indonesia, where parent
Chapter 6
Required is a
signicantly
scaled-up
approach that
centers on
community
mobilization
91
NGOs are establishing daughter NGOs at the local level to mobilize communities to plan and provide themselves with sustainable access to basic sanitation. Depending upon local circumstances and preferences, services may be
provided at the household, neighborhood, and community-wide levels. Key
to this approach is the principle of rights and responsibilities, which provides that all people in a village community have both the right to a clean and
healthful living environment and a shared responsibility to avoid disposing of
their waste in ways that adversely affect the cleanliness and healthfulness of
their living environment. This principle of rights and responsibilities is central to efforts that focus on total sanitation coverage or no open defecation
within project communities. Examples of total sanitation coverage include the
Orangi Pilot Project in Pakistan, the condominial and simplied sewerage system in Brazil, and community-led total sanitation, all of which are discussed
in the case studies (appendix 1).
Community-led total sanitation has been implemented in a number of
countries, such as Bangladesh, India, Cambodia, Indonesia, Mongolia, and
Zambia. It has also been implemented for more than 20 years in rural sanitation programs in Tanzania (in the Wangingombe Rural Sanitation Project
nanced by UNICEF) and in Zimbabwe. As practiced in Bangladesh, it starts
with strict proscriptions against capital subsidies.7 It begins with a community-organized appraisal of current sanitation practices (typically, open defecation). Residents undertake a mapping exercise in which their households and
places where defecation occurs are identied. Facilitators accompany residents
on a tour of the community. The group visits defecation areas; calculates the
amounts of feces produced; analyzes routes of contamination (through dirt,
ies, and animals, for example); and estimates how much excreta each person in the community ingests each day. The resulting combination of disgust,
shame, religious precepts for cleanliness, and self-respect typically trigger a
collective decision to end open defecation in the community.
Alternatives to open defecation are pursued by households per their preferences and ability to nance the improvements; simple pits and various types of
latrines are typically installed. Emphasis is placed on local designs and affordable materials. Communities that have undergone the community-led total
sanitation process often erect signs at the entrances to their villages proclaiming that they are totally sanitized. The resulting social solidarity can provide a
base for further collective action.
Galvanizing support for sanitation and hygiene
The absence of sanitation and hygiene from much of the discussion about
water, health, and development has found various explanations over the years.
What is clear is that excreta and its disposal have been, and continue to be,
unpopular subjects from the local to the international levels. Without strong
champions to raise public awareness and generate concern, the sanitation cri-
92
Part 1
Simply
studying
what people
are doing
can prompt
discussion
and debate
sis has not been met with anything resembling the kind of response necessary to make substantial and sustainable gains. It is instructive to consider
how another difcult topicHIV/AIDSwas freed from its own cultural
taboos and transformed into a leading global health concern.
It is true, of course, that HIV/AIDS has affected both wealthy and lowincome families in both rich and poor countries around the world, providing
a foundation for solidarity that is broader than that in the case of sanitation.
Nonetheless, the way in which that solidarity was cultivatedthrough simple,
consistent messages and a single, coherent call for actionhas much to do with
the successful marshalling of support and resources to combat HIV/AIDS. For
sanitation, the impact of a similar coordinated awareness campaign has already
been felt, as evidenced by the addition of the sanitation target to the original
Millennium Development Goals in Johannesburg.
The Water Supply and Sanitation Collaborative Council deserves much
of the credit for leading this international call to action for sanitation. The
Councils advocacy campaign Water, Sanitation and Hygiene for All (WASH)
has had considerable impact at the international level. The Councils effectiveness arises from its structure as a coalition of key-sector players, whose efforts
and messages have been effectively coordinated to reinforce one another. The
WASH campaign has also highlighted the importance of simple and accurate
information for shaping opinion and raising awareness. Several key information gaps still remain which, if pursued, could help identify the most effective
and appropriate ways to increase access to sanitation.
At the national level there is also a need for information and coherence of
action. Focused efforts to document the ground reality of sanitation practices
can help initiate dialogue among decisionmakers, professionals, communities,
and households about ways to address decits in service. Simply studying what
people are doing and exploring how they have changed their hygiene habits
over time can also prompt discussion and debate.8 Eventually, however, decisions regarding public funds and institutional restructuring to advance the
sanitation agenda will require the cooperation of elected ofcials. Again taking
a lesson from global experience with HIV/AIDS, it must be recognized that
politicians have a stake in signicant development issues; they should be drawn
into, rather than be excluded from the debate.
Finally, the strengths of the WASH campaign can and should be replicated
at local level. By drawing more people into the process of promoting sanitation,
both the strength and the coherence of the message will grow until it is undeniable. Developing a critical mass of concerned, vocal advocates for improved
sanitation within communities is not only helpful for propelling change at
all levels, it is essential for sustaining the service improvements effected far
beyond the Millennium Development Goals process.
Chapter 7
Technology and infrastructure
To expand services to the millions of people who need to be reached in order

to meet target 10, technology and infrastructure are indispensable. They are
needed to produce savings in time, labor, and cost; they are needed to deliver
convenience, efciency, and reliability of service. Fortunately, a wide range of
technological options is available for possible use in the expansion of service;
however, not all of them are appropriate or available for use in every situation.
Hence, there is a need for guidance on technology selection, strategies for cost
reduction, and the need for innovation in technology and infrastructure. A
starting point should be a quick review of available technological options.
Available technological options
Available technological options differ in many ways. They differ in scale and cost.
There are options for different community sizes and densities. There are options
for community types, such as rural areas, small urban towns, large towns, and
megacities. For water supply, for instance, there are different types designed to
match the occurrence and sources of water, treatment needs, the socioeconomic
status of intended users, and the location and size of the consumption area in relation to the source (tables 7.1 and 7.2). While each of the various options has its
time and place, the question that arises is how best to choose among them.
The choice among technological options should be driven in part by the
approach to be followed in providing coverage and, in part, by factors specic
to the technologies. In choosing technology for a particular approach, the recommended criteria are the same ve that should be satised in a nancing
strategy for target 10, plus a sixth criterion. They are:
Maximum scalability.
Minimum transactions costs.
Full nancial accountability.
94
Part 1
Table 7.1
Water supply
technologies
Water source
Abstraction
structure
Abstraction
equipment
Required
treatment
Applicable
situations
Large-scale; for
large cities or a
number of cities
and communities
Surface water (rivers,

streams, lakes)
Dams
Direct pumping
(lakes, perennial
rivers, ponds)
for storage in
adjacent surface
reservoirs
(Metropolitan
Water Board,
London)
Electric pumps
Clarication
involving removal
of solids and
turbidity;
disinfection;
corrosion
prevention
treatment (water
conditioning)
Ground water
Small-diameter
wells
Boreholes
Tube wells
Electric/hand
pumps
Mostly
Large-scale
disinfection
systems
Institutions
to combat
Domestic and
distribution
small-scale
system
agricultural
contamination
uses
Mostly no
treatment for
household
use
Wells
Large-diameter
wells
Dug wells
Mechanically
dug
Hand pumps,
mostly; also
electric
Mostly no
treatment
necessary other
than disinfection
Village
community
use
Household
uses
Ground water
Spring water
Protected
spring box
Springs provided
with protective
box with open
bottom and
outlet pipes
overowing
continuously,
leading directly
to distribution or
to storage tanks
No treatment
normally
provided
because such
spring water is
normally potable
Rural sites
Rainwater
Roof
catchment
into domestic
tanks
Ground
surface
catchment
into storage
ponds (as in
Bermuda)
None
Simple
mechanical
pumps
None or simple
disinfection
Islands with
no surface or
groundwater
sources
Small rural
communities
Households
Saline water
Pumping from
ground or
surface, such
as seas
Electric pumps
Desalination,
including reverse
osmosis
Water-scarce
areas with
access to sea
or saline water
sources
Closed revenue cycle.

Technical feasibility.
Operational and environmental sustainability.
These are discussed at length in chapter 9 under nancing strategy for the
poorest. In addition, the choice between alternative technologies for expansion of service should also take into account a number of other factors:
Supply and demand.
Sustainability of service.
Type of service provision.
Chapter 7
Table 7.2
Selected
technological options
for sustainable
access to sanitation
Type of
system
On-site
sanitation
Off-site
sanitation
95
Purpose
Technological options
Conditions suited for use
Excreta disposal
Simple, unventilated, doublepit toilet: used one pit at a

time while the other rests until
fully decomposed contents
are safe to use on land
Low water usage; poor soil

permeability; low water table;
low to medium housing density
Pour-ush toilet with twin

soakaway pits, reused
and rested alternately;
intended for emptying
Medium water use; ablution

water; good soil permeability;
low water table; low to
medium housing density
Pour-ush toilet plus

septic tank with twin-pit
soakaway pits, reused
and rested alternately
High water usage; poor soil

permeability; high housing
density; high water table
Compost toilets (Ecosan toilet)
Low water usage
Wastewater
disposal
Separate twin-pit soakaway

system for sullage disposal
Medium-high water usage;

on-site sanitation to
dispose of excreta
Wastewater
conveyance
Low-volume ush water closets

with simplied sewerage or
with small diameter, shallowdepth, and at-gradient sewers
High water usage;poor

soil permeability; high
housing density; high water
table; on-site sanitation
to dispose of excreta
Primary
treatment
Pour-ush toilets or low-volume

ush water closets with Imhoff
Tank and sludge-drying beds
Small communities and

medium towns with
high water usage
Low-volume ush toilets

with conventional primary
treatment, screening, grit
removal and sedimentation
For medium to large

towns and megacities
Secondary
treatment
Trickling lters with sludge

digesters of co-composting
of sludge with garbage
Long-term solution to
wastewater disposal in
medium to large cities
Alternative
treatment
options
Constructed wetlands
Areas where odor risk is low
In-stream wetlands and

waste-stabilization ponds
Type of access.
Desired level of service.
Community preference.
Institutional and technical capacity considerations.
Matching supply and demand

A fundamental problem in the past has been a mismatch between supply and
demand, rooted in a failure both to appreciate the importance of responding
to user preferences and to understand the real ability of people to pay for services. Traditionally, sector planners have developed demand projections from
population growth projections translated into hypothetical demand (such as
presumed willingness to forgo something important to pay for new service).
This supply-driven approach leads to a waste of scarce resources because the
intended consumers often ignore the installed facilities altogether, making
them very expensive in per capita beneciary cost (Wright 1997). For example,
in Accra, Ghana, after 20 years, only 130 connections had been made to a
96
Part 1
It is
imperative to
respond to
user demand
sewerage system intended for 2,000 connections. In Howrah, India, no one

connected to a sewerage system built for workers; and in Addis Ababa, Ethiopia, after 10 years, only 10 percent of the expected connections had been made
to the new sewerage system (Wright 1997). Tempting as it can be for professionals to push their favorite technologies, it is imperative to respond to user
demand as expressed in their preferences and their willingness to contribute to
acquisition, operation, and maintenance expenses. Even the poorest community should have to incur a cost in the form of cash (however small) or in-kind
contributions toward the capital cost of the types of desired technologies.
Sustainability of service
It has been noted in chapter 3 that the concept of sustainability has an operational or service aspect and an environmental aspect. To be sustainable in
operational and service terms, access should be secure, reliable, and available
on demand by users on a long-term basis. For this, the following are required:
A choice of technology that is responsive to demand.
Proper design of the chosen technology.
Installation of the infrastructure in accordance with the design.
Use of the installed facility as intended in the design.
Maintenance of the facility to ensure proper functioning.
Availability of competent technical staff or technical support for all of
these requirements.
A reliable ow of revenue to pay for all of these requirements.
Sustainability suffers when any one of these factors is absent. Each of them
involves the performance of actors, which is driven by the incentives they face.
Thus, sources of perverse incentives, like free-rider problems and principalagent difculties, should be identied and corrected.
Types of provision, access, and service level
Expansion of service can be achieved through public or private provision,
through self-provision, or by informal sector provision. Service can be delivered
through private access, such as house connection to a public water-distribution
system or to a public sewerage system; it can also be delivered through on-site
facilities, through vendors, or through private contractors. Each of these means
of service delivery has a corresponding type of technology that is appropriate
(table 7.3). For example, the use of self-provision, informal provision, public
provision, or private-sector provision determines, in part, the scale of service.
This, in turn, determines what type of infrastructure or technological option
would be appropriate. Thus, sewerage is not a technology of choice for private
provision, nor is roof catchment technology appropriate for public provision. If
the scale is large, economies of scale become important in technology choice.
Factors of the type illustrated in table 7.2 should be taken into account in technology choice, irrespective of nancing constraints.
Chapter 7
Table 7.3
Water and sanitation
service levels
97
Access to water supply service

Type of
provision
Type of
access
Type of
service
Technology
needed
Public
intake
structures;
House
treatment;
connection
public
distribution
systems
Public or
private
sector
provision
Access to sanitation service

Type of
provision
Type of
access
Public or
private
sector
provision
Type of
service
Technology
needed
Sewerage plus
treatment
plants
Low-volume ush
water
closets;
house connections;
simplied
sewerage;
oxidation
ponds or
ditches;
trickling
lters; Imhoff tanks
Private
access
Yard tap at As for

household house connection,
level
plus home
storage
tanks
Public
access
Informalsector
provision
Private
access
Public
standpost
Private
access
Septic
tanks;
soakaway
pits or
Septic tank absorption
systems
trenches;
water
closets or
pour-ush
toilets
Pour-ush
toilets
Selfprovision
Vendor
service
Water
tanker
trucks;
home storage tanks
VIP latrines
Private
wells
Hand or
electric
pumps;
home storage tanks
Non-ventilated pit
latrines
Storage
Roof
tanks with
catchment or without
pumps
Selfprovision
Informal
access
Provision
by public,
private
Home
business,
Unprotect- treatment; or NGO
ed sources home storage tanks
Public
access
Public
latrines
Squat
slabs over
pits or connected to
offset pits
Public water closets;

public VIP
latrines;
public
pour-ush
toilets;
public nonventilated
latrines
Institutional and technical capacity

Another key factor in technology choice should be the availability of appropriate
institutional and technical capacities for supervising design and construction
stages of water supply and sanitation infrastructure, and for ensuring proper
operation and maintenance of installed systems. In addition, there should be
appropriate institutional arrangements for training and hygiene education to
ensure proper use of installed facilities and to encourage behavioral changes
aimed at inculcating regular hand washing and good personal hygiene. The
technology should match the institutional and technical capacity that is likely
to be available at every stage of installation and implementation of the water
98
Part 1
Costreduction
strategies
help to
stretch
available
funds and
technologies
supply and sanitation infrastructure. Ideally, such capacity should be in place

before technology is chosen and installed. In line with the recommendation on
learning by doing, however, it should be sufcient to determine what level of
capacity needs to be developed and to take credible steps to put it in place during project implementation, rather than delay the intervention. Instruments to
monitor performance and benchmark progress should also be put in place to
create incentives for the necessary capacity building.
Cost-reduction strategies
Cost-reduction strategies help to stretch available funds and technologies to a

much bigger population than is otherwise possible. Examples of cost-reduction
strategies include:
Widening technological options.
Decentralization and unbundling.
Using water-saving plumbing xtures.
Using appropriate design standards.
Using multipurpose infrastructure.
Widening technological options
Through the work of a number of governments; private enterprise; and external
support agencies, including the World Bank, donors, and nongovernmental
organizations, a wide range of technological options are now available for water
supply and sanitation. The use of a demand-driven approach requires that users,
both women and men, should be provided with a range of technically feasible
options, each with information on its attributes, benets, and costs. It should
be possible for consumers to use any of the choices presented to them, provided
they want them and are willing to pay their portion of the cost, either in cash
or in kind. At the same time, consumers should be free to use their own designs
outside the choice-set presented to them, as long as the consumer choices are
technically feasible and meet the test of sustainability, as already dened.
The use of a wider range of feasible technological options is important not
only because it helps to satisfy the demand-orientation we are advocating, but
also because it enables consumers to feel a sense of responsibility for what they
perceive to be their best choice. It also forces cost comparison among options
and thereby helps to reduce technology cost.
Decentralization and unbundling
The cost of sewerage is a function of the average sewer diameter, average depth,
and total length. For large urban areas, unbundling a service area into parallel
independent service zones, each with its own sewerage network, tends to result
in a lower average diameter and average depth for the entire city. This leads
to lower capital costs, thereby helping to stretch available funds to provide
more coverage. The division of a large city into smaller decentralized areas
Chapter 7
For large
urban areas,
unbundling a
service area
leads to lower
capital costs
99
has three additional benets. First, it allows investments to be made in phases

in line with available funds. The normal alternative has been to wait until
enough funds could be mobilized for the entire city. The use of this centralized
approach has resulted in master plans that have not been implemented for 40
years or more in some instances. Such plans become obsolete by the time funds
become available for their implementation.
The second feature of unbundling is that it is associated with management
of smaller areas of service. This is much easier than management of an entire
megacity. It is estimated that unbundling can reduced the cost of sewerage by
as much as 30 percent (Wright 1997). Bangkok is a megacity where unbundling of sewerage is being successfully applied.
The third advantage is that it allows for market segmentation by getting
away from the one size ts all approach and allowing differential service
provision to different socioeconomic groups.
Use of water-saving plumbing xtures
Water-saving plumbing xtures reduce the quantity of water demanded and
the quantity of wastewater produced, thus lowering the cost of water supply
and sanitation infrastructure. Water-saving xtures allow for reductions in the
size and cost of water mains, water distribution network pipes, and sewers.
Moreover, the use of such xtures reduces water and sewer bills, thereby making such services more affordable to users. The pour-ush latrine and low-volume ush toilets are examples of water-saving devices in sanitation. The pourush toilet uses only about 2 liters of water per ush. The conventional water
closet uses about 15 liters of water per ush. New low-volume ush toilets now
mandated in the United States use only about 6 liters of water per ush. New
standards in the United States require the use of automatic shutoff valves and
other water-saving devices in a range of plumbing xtures. The use of such
devices in the pursuit of target 10 is highly recommended.
Use of appropriate design standards
One of the major problems in infrastructure design in developing countries is
the adoption of technical design standards from developed countries without
adaptation to local circumstances. Some of the design standards in place in
developed countries, especially for sewerage, were established more than a century ago. Although sector professionals are anxious to update these standards
to bring them in line with advances in theory and technology, local bylaws
constrain them. For example, the maximum length of rods that are used to
clean such sewers originally drove the spacing of manholes in sewerage. Today,
the use of hydraulic sewer cleaning devices renders obsolete adherence to the
old design standard for manhole spacing. With hydraulic cleaning devices,
manholes can be spaced much farther apart, making the entire sewerage system more affordable, because manholes contribute signicantly to the cost of
100
Part 1
A welcome
innovation
in sanitation
would be
aesthetically
acceptable
compact
sewage
treatment
plants
sewerage. Yet, many developing countries that do not have the constraints facing engineers in the developed countries continue to use, without modication, the design standards copied from the developed countries. Brazil and
Australia have made signicant advances in updating sewer design standards.
Simplied sewerage is an example of new sewer design standards that give
its users the same, if not better, standards of service at a fraction of the cost
of using conventional sewerage design standards. The adoption of such progressive design standards, adapted as appropriate to meet local imperatives, is
highly recommended.
Use of multipurpose infrastructure
In many rural areas, residents are more interested in access to water for agriculture than for drinking and sanitation, and typically much more water is
needed for agriculture than for domestic purposes. Therefore, the marginal
cost of increasing the quantity of water provided for agriculture to also meet
domestic needs would be negligible in many instances. Opportunities for multiple uses of a water distribution system can thus reduce the cost of expansion
of water supply and sanitation services.
The need for innovation
Some 30 years ago, it was thought that identifying a range of low-cost technological options would solve the problems in expansion of coverage of water supply and sanitation services. The World Bank undertook a worldwide two-year
research project that identied such options and made information about them
widely available. Nonetheless, repeated calls are made for innovation in water
and sanitation technology. What is not clear are the gaps that such technological innovation should be designed to ll. While the absence of innovation in
water and sanitation technology does not constitute an absolute constraint in
the pursuit of target 10, innovation should be pursued in those areas that can
make life-transforming changes in the expansion of access. In water supply,
one example would be desalination of saline water. Several technologies are
available for desalination (for example, reverse osmosis and distillation), and
desalination methods are already competitive with other sources of water in
some regions. The high cost of energy is the major constraint to the use of
desalination as a means of bringing water to millions of people. Research is
therefore needed to reduce the energy cost of desalination methods.
A welcome innovation in sanitation would be the development of aesthetically acceptable compact sewage treatment plants that could be used close to
residential areas. The availability of such compact plants would facilitate the
unbundling of sewerage systems. One such example has been developed for a
form of sewage treatment known as the activated sludge system. Normally, such
systems have a number of units arranged in a horizontal series. Consequently,
they take up a lot of space, a requirement that makes them impracticable in
Chapter 7
Innovations
could speed
progress
toward the
achievement
of target 10
101
congested cities. Japan, Germany, the United States, and the United Kingdom
are now experimenting with activated sludge treatment plants in which the
units are stacked one above another, thereby saving a lot of space. Some of
them have even been built under public garages. This innovative system works
very well, but its cost puts it beyond the reach of many developing countries.
Research is needed to make this approach affordable.
Another desirable innovation would be the introduction of incentives to
stimulate the creativity of users in developing locally appropriate technologies
for both water and sanitation. This is likely to happen if externally developed
technologies are not imposed on developing countries or made a condition for
receiving nancial or technical support.
In sum, many technological options are already available to expand coverage of water supply and sanitation systems in a range of circumstances. At
issue is the best way to make choices to meet specic local needs. The recommended criteria can be used to facilitate selection of appropriate technologies,
and strategies are also available to reduce the cost of many technologies. Nonetheless, innovations could speed progress toward the achievement of target 10,
for example, by reducing the cost of desalination or speeding the development
of aesthetically acceptable compact sewage treatment plants and on-site methods, such as composting toilets that use little or no water.
Chapter 8
What would it cost?
What would it cost to meet the Millennium Development Goal for water
and sanitation? Answering this question requires analysis at two levels: global
and national. Global-level estimates are helpful in giving a sense of the magnitude of what is required. Global estimates are also useful for advocacy purposes, as comparisons between what would be required to meet the global
water and sanitation goal and what the world as a whole is currently spending
its money on can be effectively jarring.
For developing countries, however, the most useful question relates to the
price tag of meeting the goal in their own countries. For this type of estimate,
individual MDG-based needs assessments are required. Thus, after a brief discussion of global costs, this chapter will focus on a national needs assessment
methodology developed by the UN Millennium Project.
Global estimates
Estimates at the global level vary. UNICEF has prepared preliminary estimates
for meeting the water supply and sanitation target, based on the number of
people to gain access and the unit cost derived from four different sources
(UNICEF 2002b). The results are indicated in table 8.1; key assumptions used
in arriving at these cost estimates are summarized in box 8.1.
As indicated, global nancing costs range from $51 billion to $102 billion
for water supply, and from $24 billion to $42 billion for sanitation for the
period 200115. There is no absolute cost gure, as much will depend upon
the technologies adopted and country-specic preferences and conditions. Taking an average would yield $68 billion for water and $33 billion for sanitation,
for a total of $101 billion and an annual average of $6.7 billion. If this seems
like a lot of money, these facts may put things in perspective: each year Europe
and the United States spend $17 billion on pet food, Europe spends $11 billion
Chapter 8
What would it cost?
Table 8.1
Cost estimates
for reaching
the Millennium
Development targets
for water supply and
sanitation, 200515
(billions of dollars)
103
Water
target
Sanitation
target
Vision 21
57
42
Joint Monitoring Programme
63
29
Nigam and Ghosh (1995)
51
24
Briscoe and Garn (1994)
102
37
Source of estimate
Source: UNICEF 2002b, based

on sources cited there.
Box 8.1
Assumptions
used in arriving
at the estimates
in table 8.1
Estimates are for a minimum package of services, in which low service levels (in
terms of technologies and costs) were applied for rural populations and intermediate service levels were applied for urban populations. The vast majority of need was
assumed to be in periurban areas and slums.
To reach these low and intermediate service levels, costs of specic technologies were
averaged.
Estimated costs include only direct construction costs. Other program delivery costs
necessary for ensuring sustainability (hygiene education, training, institutional development, and operation and maintenance costs) are not included. Nigam and Ghosh
proposed an additional cost of 10 percent as being appropriate.
While population growth over the 15-year period was accounted for, unit costs were
assumed to be constant.
Where sanitation costs are given on a per facility basis, each household sanitary facility is assumed to accommodate ve people. Water costs are given on a per capita
basis.
The 100 million slum dwellers targeted in the Millennium Development Goal are
assumed to be distributed over the regions by applying the proportion of urban populations unserved by region in 2000.
on ice cream; and the world as a whole spends $18 billion on makeup and $15
billion on perfume (Worldwatch Institute 2004).
National estimates: a method to assess needs
A needs assessment is required for countries to answer the basic question of what
and how much is needed to meet the Millennium Development Goals by 2015.
The UN Millennium Project has developed a comprehensive needs assessment
methodology that countries can use to determine the magnitude of investments
required to meet all the Goals.1 This section explores in detail the way in which
the methodology can be used to identify the specic water supply and sanitation
investments needed to meet target 10. Since the importance of water for meeting the Goals extends beyond ensuring access to safe drinking water for domestic consumption, we argue for a broad-based, integrated approach to managing
water resources and providing effective access to water supply and sanitation.
The specic interventions for meeting target 10 fall into four broad categories:2
104
Part 1
A needs
assessment
starts by
identifying
the necessary
interventions
Extension, rehabilitation, and operation of water supply and treatment

infrastructure.
Extension, rehabilitation, and operation of sanitation and wastewater
treatment infrastructure.
Promotion of hygienic behavior by households and proper use of water
supply and sanitation facilities through hygiene education and behavior
change programs.
Extension of infrastructure for water storage and transport coupled with
integrated water resources management (IWRM) to ensure adequate
supply of water for domestic, agricultural, and industrial use, as well as
ecosystem functioning.
The needs assessment for water and sanitation builds on existing work in
this area, including studies carried out by the Cambridge Economic Policy
Associates (Palmer and others 2003), the Global Water Partnership (GWP
2000), the Water Academy France (Smets 2003), WaterAid (Terry and
Calaguas 2003), and the World Water Council (WWC 2000).
A needs assessment starts by identifying the necessary interventions
broadly dened as goods, services, and infrastructure. Whereas interventions,
such as the provision of antiretroviral drugs to treat HIV/AIDS or the construction of new schools to achieve the primary education goal, are crucial for
developing an investment plan for the Millennium Development Goals, they
are quite distinct from the policies that need to underpin and deliver them,
such as regulatory changes, decentralization of the health systems, or legislation to combat stigma. A simplied distinction between interventions and
policies is that interventions describe what to do and allow us to specify how
much of each activity is needed, while policies describe how to do it.
In a second step, targets for water and sanitation coverage to be achieved by
2015 are dened for each set of interventions. Using detailed investment models, countries can then project the human resource, infrastructure, and nancial needs for meeting the water supply and sanitation target. These results can
be rened iteratively to take account of synergies with interventions in other
areas. Below we outline the specic assumptions made for the water and sanitation sector before reviewing results for a number of countries.
Our analysis differentiates between rural and urban areas, because they
are so different in existing coverage, applicable technologies, and unit costs.
To account for the need to gradually build up interventions and the human
and organizational resources that deliver them, we tentatively project a linear
scaling up of investments. The needs assessment model is exible, so that this
assumption can be easily modied. The costs for operation and maintenance
are applied to the full stock of infrastructure. Finally, water supply and sanitation facilities for schools and hospitals have been included in the education
and health sector analyses, respectively, with the exception of water supply for
schools, which has been included in this section.
Chapter 8
The data
suggest
considerable
variation in
coverage
across
countries
and between
urban and
rural areas
What would it cost?
105
Water supply and treatment infrastructure

Coverage data for access to water supply are based on the Joint Monitoring
Programme estimates for 2002 (WHO/UNICEF JMP 2004). We have corroborated these revised estimates with national sources and have also included
estimates of the percentage of existing infrastructure that is not functioning,
assuming that these facilities will be gradually rehabilitated until 2015 at 50
percent of the replacement cost. Data from the most recent Demographic and
Health Survey for each country are used to approximate the percentage of
users having access to a particular technology.3 The data suggest considerable
variation in coverage across countries and between urban and rural areas. We
have applied simple rules to project which technologies will be used for increasing access to water and sanitation.
For rural water supply, we estimate the relative shares of each technology
according to the following principles: 4
Avoid an increase in the number of people depending on rainwater in
those areas where rainfall is highly variable.
Limit growth in public standposts (also known as public water taps)
to the rate of population growth over the period to increase revenue
collection.
Assume that the share of household connections will reach the same
proportion of the population as public standposts by 2015.
Place the primary focus on water sources that require little or no treatment and impose minimal distribution costs, such as groundwater, spring
water, upland water that reaches consumers by gravity, and rainwater.
Increase the share of boreholes to half the share of improved dug wells,
as dened by the Joint Monitoring Programme, subject to technical
feasibility.
For urban water supply, we use the two basic principles:
Improve revenues from user charges, shift from standposts to household
connections.
Limit growth in access to dug wells, boreholes, and public standposts
approximately to population growth rates.
Capital costs for each type of technology vary across countries and have
been collected from a number of sources, including WHO and UNICEF
(WHO/UNICEF JMP 2000), national water ministries, project documentation from multilateral and bilateral organizations, and nongovernmental organizations. Unfortunately, data on capital cost tend not to be differentiated by
urban and rural areas. Two opposing trends make it difcult to estimate the
cost differential between urban and rural areas. On the one side, capital costs
and salaries tend to be much higher in urban areas. On the other, lower population densities and longer distances can imply a higher cost of providing rural
populations with access to water. On balance, we assume that rural capital costs
for boreholes, rainwater collection, and dug wells are about 40 percent of the
106
Part 1
Community
mobilization
and
awareness
raising can
require
substantial
resources
that must
be included
in the needs
assessment
urban cost, while household connections and public standposts are assumed to
be twice as expensive as in denser urban areas.
In addition to the resources required for water supply infrastructure, we
include the cost of raw water provision and general operation and maintenance
expenses. While some data exist on the price of water, mainly in urban areas,
we have not been able to identify reliable data on the cost of providing water.
The high variation in the cost of providing water locally was a complicating
factor. A second problem is that many countries provide direct and indirect
subsidies to the cost of drinking water, so that available cost data are insufcient for approximating the true cost of providing safe water. For these reasons,
we have included the cost of treating and providing safe drinking water in
overall operation and maintenance expenses.
Based on information provided by various members of the task force, the
cost of maintenance and operation, including the cost of providing safe drinking water, ranges between 5 and 10 percent of the capital replacement cost.5
Accordingly, this range has been applied to the different technologies, depending on the complexity of their maintenance.
Chapter 5 described how community mobilization and awareness raising
need to accompany the provision of new water supply and sanitation infrastructure. These interventions can require substantial resources that must be
included in the needs assessment. Typically, though, such programs for water
supply and improved sanitation are combined into a single campaign. To
avoid double counting, we have therefore estimated the resource needs of all
community mobilization programs as part of the sanitation needs assessment
described below.
Sanitation and wastewater treatment infrastructure
Coverage data for access to sanitation are based on the Joint Monitoring Programmes estimates for 2002 (WHO/UNICEF JMP 2004). In contrast to
water supply, no reliable data were available on the extent of sanitation infrastructure that is not functioning. Based on interviews with experts, we assume
conservatively that 15 percent of sanitation infrastructure is defunct. Just as for
water supply infrastructure, we project that these facilities will be rehabilitated
by 2015 at half the cost of construction.
In line with our analysis of water supply, the current coverage of sanitation
technologies was derived from the most recent Demographic and Health Survey data.6 The relative technology shares for rural sanitation were estimated
based on the following assumptions:
Make no additional public investment in the extension of conventional
sewerage, simplied sewerage, or in septic tanks, except where such sewerage can be linked to high-density housing areas, residents from whom
costs can be recovered, or efuent use for agriculture.
Chapter 8
We assume
conservatively that
15 percent
of sanitation
infrastructure
is defunct
What would it cost?
107
Split the remaining service gap equally among pour-ush toilets, ventilated improved pit (VIP) latrines, and pit latrines.
For urban sanitation, the applied set of assumptions is:
Limit the increase in connections to conventional sewerage to areas
within the current sewerage boundaries, assuming that existing conventional sewerage has enough capacity for twice the current population
coverage.
Provide simplied sewerage for at least 50 percent of those with house
connections to public water supplies.
Discourage growth in septic tank use, and limit any such growth to
no more than 10 percent of the current level;7 all septic tanks should
include two parallel sets of soakaway systems designed to be used one
at a time for a year, after which the system in use would be rested while
the other one is brought into service.
Distribute the rest of the coverage gap equally among pour-ush, VIP
latrine, and pit latrines.
Provide properly attended and maintained public toilet facilities in congested public places, as done by Sulabh International in India.8
Capital costs have been collected from the same sources used to estimate
costs for water supply. We distinguish between two sets of operating costs for
sanitation systems: First, the resources required for maintaining the physical
infrastructure, including local treatment of the excreta, such as emptying of pit
latrines, VIP latrines, and septic tanks. Based on information provided by the
task force, we estimate the total operation and maintenance costs of the rst
type to be between 5 percent and 10 percent of capital cost.
Second, operating costs are incurred from on-site education accompanying
the rollout of infrastructure required to promote proper use, operation, and
maintenance of sanitation facilities. Available estimates for these costs range
from less than 10 percent of capital cost globally (Acadmie de lEau 2003)
to 15 percent of capital costs in South Africa (Muller 2003) and 20 percent in
India (Shekhar 2003). We have used the latter estimate for our calculations,
which accounts for the full range of activities accompanying the installation of
new sanitation facilities.
As described previously, some wastewater treatment may be required for
sewered sanitation systems, particularly in densely populated urban and rural
areas or in the vicinity of fragile freshwater ecosystems, such as shallow lakes.
Our tentative target for wastewater treatment is to provide primary or secondary treatment to approximately 60 percent of all households with access
to sewerage (conventional or simplied). We currently exclude tertiary and
advanced industrial wastewater treatment from this analysis, assuming that
these investments can and should be nanced by the private sector, which
generates wastewater requiring such treatment. It can, however, be argued that
industrial wastewater treatment ought to be part of publicly provided infra-
108
Part 1
We emphasize the
importance
of meeting
needs for
water storage
infrastructure
structure to facilitate the creation of urban employment opportunities, while

safeguarding the health of the population, as is the case in countries in Europe
and North America. Evidence from India supports this argument: the Indian
government is struggling to enforce its wastewater treatment program without driving small industries that cannot afford to pay the cost out of business
(Cosgrove 2003).
Hygiene education and behavior-change programs
As in other areas, public education and behavior change programs can take
a number of forms, including the deployment of community workers, the
creation of mass media campaigns, and the formal integration of water and
hygiene education into school curricula. The best approach typically comprises
a mix of these interventions and will be time- and context-specic. Our needs
assessment of hygiene education and behavior-change programs focuses on two
core components: rst, mass media campaigns to promote hygienic behavior
and to discourage wasteful consumption of water and second, water and sanitation education at primary schools. These two sets of interventions complement community-based programs that precede and accompany the rollout of
infrastructure.
In the absence of specic estimates for the water and sanitation sector,
resource estimates for mass media campaigns and education components at
primary schools are based on budgets for equivalent awareness campaigns
and prevention programs against HIV/AIDS (UNAIDS 2002).9 We assume
conservatively that each country runs a mass media campaign once every
two years.
Water storage, transport, and integrated management
The country needs assessments do not quantify countries water storage needs
for meeting the Millennium Development Goals. Doing so would require a
more detailed country-specic analysis, taking into account appraisals of water
consumption for productive and domestic use, economically viable storage
potential, adverse impacts on the environment, and the need for resettlements.
The World Commission on Dams highlights how difcult it is to reconcile
economic, social, and environmental needs (World Commission on Dams
2000).
Nevertheless, we emphasize the importance of meeting needs for water
storage infrastructure as part of a national Millennium Development Goals
planning effort (as described further in part 2). Rough calculations suggest
that countries in Sub-Saharan Africa might need to invest between $150 and
$700 per capita to reach a level of water storage infrastructure equivalent to
South Africas (Grey and Sadoff 2002). Spread out over the 10 years between
2005 and 2015, these investments would amount to $15$70 per capita. We
do not know whether these gures represent the right order of magnitude of
Chapter 8
The focus
has been on
developing a
methodology
for national
needs
assessments
What would it cost?
109
investments required and what share of these investments might be amenable

to private nancing. Given the importance of water storage in the tropics of
Africa, this area requires urgent attention and more analytical work.
Integrated water resources management (IWRM) in Ghana, Tanzania,
and Uganda consists largely of improved policies and coordination mechanisms. While successful IWRM will require resources, these are difcult to
quantify and have so far not been included. A draft study prepared by the
Danish Ministry of Environment estimates that implementing IWRM in the
Central Asian and Eastern European countries might cost between $0.03 and
$0.35 per capita (Jnch-Clausen 2003). These results suggest that per capita
investment needs for IWRM may be very modest.
Illustrative results
To reach the Millennium Development target for water and sanitation by
2015, planning should be carried out at the national and subnational level,
with needs assessments at the national level as well. Because community preferences, applicable technologies, unit costs, technology standards, and so forth
vary from country to country, the Millennium Project has not prepared a global
estimate of the nancing needs for water and sanitation. Instead the focus has
been on developing a methodology for national needs assessments and then
applying it in a number of countries. We emphasize that the results presented
here are the product of an outside-in analysis and will need to be revised by
a national-level planning process.10 We do believe, however, that the results
indicate the right order of magnitude of investments required in the sector.
A preliminary needs assessment for Ghana (using the methodology described here and in detail at the UN Millennium Project website) quotes total
investment volumes for the years 2005, 2010, and 2015, underlining the gradual scaling-up of investments (table 8.2). The columns on the right provide
total investment needs and averages over the period from 2005 to 2015. The
lower table divides investments by the total population (not the population
served) to obtain per capita estimates of the resource needs.
The analysis assumes that investments in water and sanitation are gradually scaled up over time to meet target 10 by 2015. Over time, operating costs,
including maintenance, are generally higher than the initial capital costs; the
magnitude of resources required for operation and maintenance are often
grossly underestimated.
Results for other countries summarized in table 8.3 exhibit a substantial
degree of variation, which results in differences in unit costs, service standards,
and operation and maintenance expenditures (see the UN Millennium Project
website for additional information on the methodology).11
We emphasize that these cost estimates are likely to understate the true
investment needs for the water and sanitation sector that are required to
meet the Millennium Development Goals. In particular, they do not yet fully
110
Part 1
Table 8.2
Resource
requirements for
reaching target 10
in Ghana, 200515
Source: UN MIllenniium Project.
Total cost estimates in 2003 (millions of dollars)
Category
2005
2010
Total
200515
2015
Average
200515
Share of
total over
period
(percent)
Water provision
Rural
Capital
cost
10,026,715
6,327,163
7,639,544
74,871,750
6,806,523
Operating
cost
15,944,164
15,012,887
14,650,132
166,297,043
15,117,913
Subtotal
25,970,879
21,340,050
22,289,676
241,168,793
21,924,436
Capital
cost
14,141,600
27,763,761
35,064,790
304,373,750
27,670,341
15
Operating
cost
33,732,643
48,904,528
67,383,252
545,650,636
49,604,603
20
Subtotal
47,874,243
76,668,289
102,448,042
850,024,386
77,274,944
35
73,845,121
98,008,339
124,737,719
1,091,193,179
99,199,380
43
Capital
cost
3,735,093
7,970,192
24,860,156
114,308,051
10,391,641
Operating
cost
3,083,993
5,126,261
9,535,140
61,225,914
5,565,992
Subtotal
6,819,086
13,096,453
34,395,296
175,533,965
15,957,633
219,489,019
19,953,547
19
Urban
Total
Sanitation
Rural
Urban
Capital
cost
14,183,612
19,706,385
24,615,225
Operating
cost
14,863,110
21,324,792
58,216,033
269,123,521
24,465,775
15
Subtotal
29,046,722
41,031,177
82,831,258
488,612,540
44,419,322
34
35,865,808
54,127,630
117,226,554
664,146,505
60,376,955
41
Total
Wastewater treatment
10,304
3,051
1,361
35,587
3,235
Urban
Rural
1,883,716
6,910,847
11,063,001
76,981,097
6,998,282
Total
1,894,020
6,913,898
11,064,362
77,016,685
7,001,517
9,776,081
81,199,248
7,381,750
262,804,715 1,913,555,617
173,959,602
100
Hygiene
education
5,305,757
7,285,891
Total cost
116,910,706
166,335,759
Per capita total cost estimates in 2003 (dollars)
Category
2005
2010
2015
Average
200515
0.5
0.3
0.3
0.3
Share of total
over period
(percent)
Water provision
Rural
Capital cost
Operating cost
0.7
0.6
0.6
0.6
Subtotal
1.2
0.9
0.8
0.9
13
Chapter 8
Table 8.2
Resource
requirements for
reaching target 10
in Ghana, 200515
(continued)
What would it cost?
111
Category
2005
2010
2015
1.2
1.3
Average
200515
Share of total
over period
(percent)
Water provision (continued)

Urban
Capital cost
0.6
1.1
16
Operating cost
1.5
2.0
2.6
2.1
29
Subtotal
2.2
3.2
3.9
3.2
44
3.4
4.1
4.7
4.1
57
0.2
0.3
0.9
0.4
Operating cost
0.1
0.2
0.4
0.2
Subtotal
0.3
0.5
1.3
0.7
0.6
0.8
0.9
0.8
11
Operating cost
0.7
0.9
2.2
1.0
14
Subtotal
1.3
1.7
3.1
1.8
26
1.6
2.2
4.4
2.5
35
Total
Sanitation
Rural
Capital cost
Urban
Capital cost
Total
Wastewater treatment
Table 8.3
Resource
requirements for
reaching target 10
in ve low-income
countries, 200515
Rural
0.0
0.0
0.0
0.0
Urban
0.1
0.3
0.4
0.3
Total
0.1
0.3
0.4
0.3
Hygiene
education
0.2
0.3
0.4
0.3
Total cost
per capita
5.4
6.9
10.0
7.2
100
Total cost estimates in 2003 (millions of dollars)

Period
Bangladesh
2006
689
Cambodia
50
Ghana
133
Tanzania
160
Uganda
63
2010
829
77
166
223
106
2015
1,178
151
263
545
336
8,719
882
1,797
2,764
1,467
Average per year
872
88
180
276
147
Average annual %
of GDP, 200615
1.0
1.3
2.0
1.6
1.2
200615
Source: UN MIllenniium Project.
Overall

2006
4.4
3.3
6.0
4.1
2.2
2010
5.0
4.6
6.9
5.3
3.2
2015
6.5
8.2
10.0
11.9
8.6
200615 average
per year
5.2
5.3
7.4
6.5
4.3
112
Part 1
reect all trunk infrastructure required for urban water supply and sanitation
systems or required investments in water storage.
Identifying the required investments through the needs assessment methodology is a critical step toward meeting target 10. Developing a strategy for
funding these investments is equally important, and to this topic we turn in
the next chapter.
Chapter 9
Grappling with nancing

for the poorest
The previous chapter analyzed what it would cost to meet the Millennium
Development Goals for water and sanitation at both global and national levels.
This chapter analyzes the nancial strategies that will be needed to cover these
costs. Given the centrality of the nancing issuenot to mention the passion that stakeholders on different sides of the debate bring to the tablethis
chapter tries to clarify several critical and often contentious issues related to the
nancing strategies needed to achieve a dramatic expansion of access to water
supply and sanitation in the poorest countries of the developing world: What
would it take? Who would foot the bill? And how could it be done?
This chapter focuses principally on the people living in absolute poverty in
low-income countries, those most off-track in terms of reaching the goals. This
focus on the poorest needs to be highlighted at the outset, because much of the
debate on nancing for water and sanitation revolves around a lack of clarity
regarding the target group. Very little of the literature, in fact, distinguishes
among the fundamentally different approaches needed to nance sustainable
access to water and sanitation for different target groups. Of course, the target
group on which this chapter focuses represents only a fraction of the more than
1 billion people without access to domestic water supply and the roughly 2.6 billion without access to sanitation. Those global gures include signicant numbers of poor people in India, China, South Africa, Brazil, Indonesia, and other
countries that have relatively sizable domestic resources for nancing water and
sanitation. The category of the unserved, particularly in the area of sanitation,
also includes signicant numbers of people who are not absolutely poor, both in
the low-income and the middle-income countries of the developing world.
The chapter also addresses nancing needs for meeting the Millennium
Development Goal on water and sanitation within the context of a comprehensive nancing analysis across all Goals for three reasons:
114
Part 1
A simple
typology
illustrates
four different
target groups
The larger goal is to meet the full set of Millennium Development

Goals, rather than only the target for water and sanitation.
Although the fact that poor people spend a lot of money on water is
taken to show that the poor can afford to pay for water charges, in
practice they may be compromising on essential expenditures for other
basic needs, such as food, transport, energy, health, or education. Such
expenditure is possible because the procurement is made a little at a
time and at frequent intervals in response to unavoidable imperatives; it
fails when payment should be made at longer intervals after the goods
in question have already been used.
This broader approach enables parallels to be drawn with approaches
that work in other areas (especially in other service-related Goals, such
as those for health and education).
Despite this cross-Goal analysis, the chapter focuses only on nancing water
infrastructure and services to meet the targets for domestic water supply and
sanitation. It does not address nancing for other kinds of water infrastructure
and servicesfor example, nancing for irrigation infrastructure projects to help
address the targets on hunger. An important document that addresses this wider
spectrum of water nancing issues is the report of the World Panel on nancing
water infrastructure (World Panel on Financing Water Infrastructure 2003).
Principal target group: poor people in the poorest countries
A simple typology, represented in table 9.1, illustrates four different target

groups within the overall population of people who currently do not have
access to water or sanitation or both.
Two examples help to illustrate the approach:
Indonesia, a middle-income country, has roughly 62 million people
without access to sanitation, 44 million without access to water, and
14 million below the poverty line (UNDP 2003). If we assume that all
people in Indonesia below the poverty line also do not have access to
improved sanitation, then the gures that would go into the boxes for
Quadrants 2 and 4 for sanitation would be:
Quadrant 2: Unserved people living in absolute poverty: 14 million.
Quadrant 4: Unserved people living above the poverty line:
62 million 14 million = 48 million.
Low-income countries
Table 9.1
Unserved people:
where are they?
Middle-income countries
Below poverty line
Quadrant 1:
Unserved people living
in absolute poverty in
low-income countries
Quadrant 2:
Unserved people living in
absolute poverty in middleincome countries
Above poverty line
Quadrant 3:
above the poverty line in
low-income countries
Quadrant 4:
above the poverty line in
middle-income countries
Chapter 9
Expanding
water supply
and sanitation
coverage
requires
money
Grappling with nancing for the poorest
115
Mali, a low-income country, has roughly 1 million people without

access to sanitation, 4 million without access to water, and 8 million
below the poverty line (UNDP 2003). If we assume that all people in
Mali without access to improved water and sanitation are also below the
poverty line, then the gures that would go into the boxes for quadrants
1 and 3 for sanitation would be:
Quadrant 1: Unserved people living in absolute poverty: 1 million.
Quadrant 3: Unserved people living above the poverty line: 0.
This chapter principally discusses strategies for countries such as Mali,
where the lions share of the unserved are living in absolute poverty.
A rough initial distribution of the global population of unserved people
for which data were available across the four quadrants for both water and
sanitation shows that the target group of unserved people living below the
poverty line in low-income countries by no means represents the majority of
the unserved, especially for sanitation (tables 9.2 and 9.3).1 However, it is the
target group most likely to be left behind if appropriate nancial strategies are
not urgently developed to reach them.
Financial constraints in low-income countries
Globally, expanding water supply and sanitation coverage requires many

things, and one of them is moneywhether from national and subnational
government tax revenues, user charges, cross-subsidies from users who can
afford to pay, private-sector investment, contributions from nongovernmental
organizations and charity organizations, ofcial development assistance, or a
combination of some or all of these sources.
For deeply impoverished countries, none of those sourcesnot even all of
them combinedcurrently provides sufcient resources to expand services as
dramatically as would be required to meet target 10. Here the challenges are
to mobilize the necessary resources from the international community, while
Table 9.2
Distribution of the
global population
without access to
safe water supply
Millions
Low-income
countries
Millions
Total
Living below the poverty line
320
96
416
Living above the poverty line
30
259
289
350
355
705
Low-income
countries
Middle-income
countries
Total
Table 9.3
Distribution of the
global population
without access to
basic sanitation
Middle-income
countries
Total
Living below the poverty line
540
93
633
Living above the poverty line
565
730
1,295
1,105
823
1,928
Total
116
Part 1
The nancing
strategy
needs to
ensure that
the poorest of
the poor are
not excluded
also working to ensure that budgetary processes, policies, and institutional

arrangements within countries give priority to investment in basic water supply and sanitation services for the poor. Governments and donors alike often
direct their resources not to poor communities where the needs for access are
the greatest, but rather to areas where there is political capture by politicians or
where the criteria for donor success, such as reforms, are in place.
Specic factors that inhibit the ow of resources required for the construction, operation, and maintenance of water supply and sanitation infrastructure
and the delivery of services were discussed at length in chapter 5. Those particularly relevant to low-income countries include the following:
Many towns and municipalities have poor access to loan nancing facilities, their tax revenues are limited, transfers from central governments
are unreliable, and local nancial markets are weak.
Water and sanitation utilities often have weak managerial and nancial
capacities and are unable, for a variety of reasons, to generate sufcient
cashow for recurrent expenditures.
Financing water and sanitation facilities is unappealing to private investors for many reasons, including the lumpiness of necessary investments, payback periods of 20 years or more, and the political difculties
inherent in charging and collecting cost-recovering tariffs.
Trends in ofcial development assistance suggest that support for water
supply and sanitation infrastructure is very modestboth in relation to
support provided to other infrastructure sectors and in terms of what is
necessary to meet target 10. In addition, the prerequisite condition normally prescribed for ofcial development assistancethat certain reforms
are in place to ensure effective and accountable use of fundshas been a
severe constraint to the countries most in need of help to meet target 10.
Some basic principles
A sound nancing strategy for meeting the water supply and sanitation Goal
in the poorest countries is to compare total nancing needs with the potential
for domestic resource mobilization by households and governments and then,
based on the gap between the two, identify external nance requirements. The
nancing needs for target 10 can be quantied through a needs assessment
covering all capital and operating costs.
The nancing strategy needs to ensure that the poorest of the poor are not
excluded. Many households are too poor to afford even minimal amounts of
clean water and therefore resort to consuming water from unimproved sources.
The fact that many urban households spend high shares of their disposable
incomes on water supply is often cited as evidence that they can afford high
water prices. While an exclusive focus on water supply and sanitation might
justify this conclusion, it becomes untenable in the context of the broader Millennium Development Goals. Since water is necessary for human survival,
Chapter 9
Many lowincome
countries
face large
nancing
gaps
117
poor households are often forced to compromise on other essential expendituresfood, clothing, healthcare, clean sources of energy, transportto
nance their minimal consumption of water. As a result, these households
may be malnourished or sick. For them water is not affordable, even though
they are currently paying more for it than the rich do. Besides, they are able to
pay as much as they do in aggregate terms only because they make procurements only to meet immediate needs, and they do so at frequent intervals and
in small amounts. However, they nd themselves unable to make the same
aggregate payments if the payment intervals are longer and the amounts they
should pay at a time are signicant.
Similar constraints operate at the level of national budgets, where countries
may be able to nance the water and sanitation objective alone, but lack the
resources required to meet the other Millennium Development Goals at the
same time. This is part of the reason that water is often absent from poverty
reduction strategies. Any sectoral nancing strategy needs to be embedded in
a nancing strategy for all the Millennium Development Goals to ensure that
sufcient resources are available to meet the full range of goals.
In addition to being affordable, a nancing strategy needs to ensure that
basic household needs for water are met without unduly wasting scarce water
resources or depriving water utilities of revenues from households that can
afford to pay. Several countries have used lifeline tariffs to reconcile affordability with the need to limit per capita water consumption and to generate water
revenues. These tariffs charge no fees or minimal fees up to the minimum
need of 2050 liters per person per day and apply the full cost for any water
consumption beyond this minimum need.
Where nancing needs exceed the potential for domestic resource mobilization by households and governments, external nancing will be required
to ll the nancing gap. Needs assessments for the full range of Millennium
Development Goals suggest that many low-income countries, particularly in
Sub-Saharan Africa, face large nancing gaps on the order of 20 percent to
30 percent of their gross domestic product, or GDP (UN Millennium Project
2005). Given the magnitude of the investments required, the extreme poverty
of the countries, and the fact that the investments are unlikely to yield a nancial return in the near future, external nance for the poorest countries will
need to be grant-based. These countries are too poor to afford loans, because
they would not be able to service the repayments.
Donors often insist on nancial sustainability for investments in infrastructure and social services, requiring that the users bear all operating costs.
Ample experience across all sectors has shown that many poor countries are
unable to nance operating costs on their own. For example, the 46 percent
of Ethiopians living below the national poverty line2 are unlikely to be able to
nance the operation of rural water supplies or urban sanitation infrastructure.
In addition, the country is too poor to either cross-subsidize nearly half its
118
Part 1
The poorest
countries
need more
aid if they
are to meet
the Goals
population or attract private investors, particularly in this sector. Clearly, if the

Millennium Development Goals are to be achieved, bilateral and multilateral
donors will need to fund substantial shares of operating costs.
The ability of low-income countries to nance the water and sanitation
In low-income countries, the nancing for meeting the Millennium Development Goals needs to come from government revenues, household income, and
external nance in the form of grants. The private sector can play an important intermediary role in nancing infrastructure, but any loans need to be
recouped from the users or the government. In countries that cannot service
loan repayments on investments in basic infrastructure and social services, the
private sector does not, therefore, provide a new source of nancing. This is
conrmed by recent experience in low-income countries, which suggests that
the private sector can at best play a marginal role in nancing the water and
sanitation target in urban areas. Of course, the private sector can, and often
does, assume a critical role in the provision and operation of water supply and
sanitation infrastructure.
As argued above, a countrys ability to nance the investments and operating costs of meeting a particular target needs to be assessed in the light of total
nancing needs for meeting all the Millennium Development Goals, which
may amount to roughly $100 per capita per year for the poorest countries.
It is impossible for low-income countries to nance investments of this order
of magnitudeeven if tax revenues are maximized and all opportunities for
cross-subsidization within the country are exhausted. These countries need
more aid if they are to meet the Goals.
As a general rule, poor countries are able to spend lower shares of their
income on the Goals, compared with middle- or high-income countries, since
a larger share of income must be devoted to meeting subsistence needs for food,
clothing, shelter, and the like. Today, a typical very low-income country is able
to devote between 5 percent and 7 percent of GDP to government expenditures on the Millennium Development Goals, in addition to perhaps 3 percent
of GDP in household user fees. We project that government expenditures can
be raised by four percentage points of GDP between 2005 and 2015, which
represents a substantial reallocation and increase in government expenditures
over a relatively short period of time. On the basis of this ambitious increase in
domestic resource mobilization, the typical very low-income country may be
able to afford between 12 percent and 14 percent of GDP by 2015. Averaged
over this 10-year period, this corresponds to approximately $35$50 per capita
per year. This leaves an annual funding gap of approximately $50$65, which
cannot be closed using domestic resources (UN Millennium Project 2005).
In contrast, middle-income countries not only have higher per capita
incomes, but are also able to devote larger shares of their GDP to meeting the
Goals. As a result, their total domestic resource mobilization exceeds annual
Chapter 9
Any nancing
strategy
compatible
with the
Goals needs
to ensure that
the poor are
not excluded
based on their
low incomes
nancing needs for the Goals. The potential for domestic resource mobilization is signicant in some representative countries (table 9.4). Some middleincome countries that right now may be able to devote as much as 15 percent
of GDP to meeting the Millennium Development Goals do not require any
external nance. However, even if low-income countries were to spend an
unrealistically high 15 percent of their GDP on the Goals, they would still
require substantial external nance to meet the roughly $100 per capita needed
each year to reach the Goals. Moreover, since middle-income countries generally have better infrastructure, as well as better health and education outcomes,
they are likely to require fewer public investments to meet the Goalseven
after accounting for the higher salary levels relative to low-income countries.
What does this assessment of aggregate nancing needs imply for poor
households in each country? As discussed above, any nancing strategy compatible with the Goals needs to ensure that the poor are not excluded from
access to improved water supply and sanitation based on their low incomes.
In practice, subsidies for capital and sometimes operating costs may therefore be required to ensure equitable access to basic infrastructure services. In
particular, the capital cost for water supply schemes in rural areas, as well as
infrastructure investments in urban agglomerations, may need to be partially
or wholly subsidized. We tentatively assume that populations living below the
national poverty line3 are unable to contribute substantially to the capital costs
of new water supply and sanitation infrastructure beyond providing labor or
sweat equity, and will require lifeline tariffs along the lines of the South
African rural water-supply model. In the poorest countries, this would affect
between 35 percent and 50 percent of the population who earn less than the
national poverty line.
In contrast to middle-income countries, where the share of population
unable to meet basic nutritional needs is of course lower, low-income countries
Table 9.4
Potential domestic
resource mobilization
for the Millennium
Development Goals
US$ per capita
119
Group and country
GDP per capita,

2001
Mobilization of
12 percent of
GDP per capita
Mobilization of
15 percent of
GDP per capita
Middle-income countries
Brazil
2,915
350
China
911
109
137
Indonesia
695
83
104
2,620
314
393
South Africa
437
Low-income countries
Bangladesh
350
42
53
Cambodia
278
33
42
Ethiopia
95
11
14
269
32
40
Tanzania
271
33
41
Uganda
249
30
37
Ghana
120
Part 1
A viable
nancing
strategy
requires a
high degree
of specicity
for each
country
do not have sufcient resources available to cross-subsidize capital and operating costs. While there may be potential for cross-subsidization at the margin,
the balance of aggregate domestic resource mobilization and nancing needs
indicates clearly that countries such as Bangladesh, Ghana, and Tanzania will
require substantial external nancing if they are to meet the Millennium Development Goals. Improved mechanisms for domestic resource mobilization and
nancing, such as improved tariff schemes or public-private partnerships, are of
course important, but alone they cannot solve the nancing problem that these
countries need to overcome to meet the Goals.
A nancing strategy for low-income countries
What might a viable nancing strategy for meeting target 10 in low-income
countries look like? Clearly, it would need to maximize domestic resource
mobilization while ensuring that capital and operating costs are adequately
funded without excluding the poor.
We are fully aware that a viable nancing strategy for water supply and
sanitation requires a high degree of specicity for each country to ensure maximum compatibility with existing institutional arrangements, the degree of
community involvement in decision-making, available economic and nancial
resources, prevailing social and cultural preferences, and so forth. For this reason we restrict ourselves to outlining key elements that we believe may help
guide the development of nancing strategies for individual countries.
In addition to the principles of affordability and incentive compatibility
outlined above, a nancing strategy for target 10 in low-income countries
needs to satisfy the following ve requirements:
Maximum scalability. Meeting target 10 in the poorest countries, while
still possible, requires progress at an unprecedented pace. For this reason, the nancing strategy needs to be one that can be scaled up quickly
and straightforwardly to allow for rapid increases in the population
served.
Minimal transaction costs. Low-income countries often have very limited institutional capacity and technical resources, which reduces their
ability to implement complex nancing schemes. For example, there
will be institutional limits to countries ability to implement cross-subsidization across households and communities, even where it may be
nancially feasible. Any viable nancing strategy therefore needs to
minimize transaction costs.
Full nancial accountability. Governments and local authorities need to
ensure that domestic and external resources are used effectively and are
not diverted away from meeting the Millennium Development Goals.
Financing mechanisms for the water supply and sanitation target will
therefore need to be transparent, which reinforces once more the importance of simple nancing arrangements.
Chapter 9
The greatest
need for
subsidies
may be to
cover capital
costs of new
infrastructure
121
Closed revenue cycle. Financing mechanisms need to be nancially viable

in the sense that all capital and operating costs are fully coveredeither
through user fees, government subsidies, or external nance.
Technical feasibility. Finally, available technologies for water supply and
sanitation may impose technical constraints on the range of feasible
nancing mechanisms. For example, public standposts can make it difcult to levy user fees or to ensure that richer households contribute
more to the operating costs.
The greatest need for subsidies may be to cover capital costs of new infrastructure. While some rural sanitation technologies, such as improved pit
latrines, may not require any signicant nancial resources except for technological components that are unavailable at the local level and labor and locally
available materials provided by the communities themselves, capital costs for
most water supply and sanitation infrastructure typically need to be subsidized
for the poorer segments of the population. A common approach is to invite
communities to choose among a range of different technology options to identify the solution that is best adapted to local needs and means, nancial or otherwise. To ensure that subsidies are targeted to the population most in need, the
level of subsidies should decrease as levels of service increase (for instance, standpipes providing water supply to several previously unserved households might
be subsidized, whereas individual household connections, the highest and most
expensive level of service, would not be). In this way, wealthier households with
a preference for higher levels of service will pay a higher share of the total cost.
It has often been found that trunk infrastructure is too expensive to be
nanced by communities in poor countries. The high cost, combined with the
public goods nature of trunk infrastructure, its positive externalities, and the
difculty in aggregating nancing from a large number of households lead us
to conclude that basic trunk infrastructure should be publicly nanced. This
applies in particular to networked sanitation systems in urban areas, as well as
wastewater drainage and treatment of both sewage and septage.
Lifeline tariffs have been used successfully to conance the operating costs
of water supply. The experience in South Africa and other countries demonstrates that lifeline tariffs help ensure that even the poorest households enjoy
effective access to sufcient amounts of clean water. Hence, we recommend
that lifeline tariffs be applied wherever technically feasible and that new water
supply systems be designed to facilitate the application of lifeline tariffs. This
notwithstanding, technical and institutional constraints will likely make it
difcult to introduce lifeline tariffs in many rural areas of low-income countries. In cases where the rural poor are unable to meet the full operating costs
of water supply, at subsidies may therefore be a viable option. Since their
domestic consumption of water will remain low, environmental constraints on
overall water availability should not be of major concern for the design of tariff
schemesexcept, of course, in arid regions.
122
Part 1
Deep-rooted
community
ownership
should attract
favorable
nancing
mechanisms
and terms
As demonstrated above, many low-income countries will require substantial external nance to meet the Millennium Development Goals. While the
modalities under which such aid should be provided go beyond the scope of
this paper and have been discussed elsewhere by the Millennium Project,4
three key principles can be summarized here:
All ofcial development assistance to the poorest countries that are signicantly behind schedule for meeting the Millennium Development
Goals should be provided in the form of grant or grant-like support.
Low-income countries should develop Goals-based poverty reduction
strategies, together with medium-term expenditure frameworks, that
include explicit provisions for meeting the water and sanitation targets.
Donor methodologies must be changed to allow countries to develop
poverty reduction strategies that realistically address the challenges posed
by the Millennium Development Goals; those countries whose poverty
reduction strategies are technically, socially, and environmentally sound
and focused on attaining target 10 should be afforded grant or grant-like
nancing to support their efforts in expanding access to services.
Subsidies for capital (and, where necessary, for operating costs) should
be established to ensure equitable access to basic infrastructure services. Capital costs for water supply and sanitation programs in rural
areas, some small towns, and urban slums may need to be partially or
wholly subsidized. Care must be taken to ensure that the particular
strategies adopted (such as capital grants, lifeline tariffs) are targeted
to poor households and are not merely beneting wealthier consumers
with network connections. Subsidies should focus on expanding access
rather than consumption.
Critically, poverty reduction strategies need to incorporate mechanisms
to ensure that funding for water and sanitation reaches the implementing
authorities. In many instances this will require transfer mechanisms to make
available funds from the national level to lower levels of government, such
as local authorities. Setting up effective transfer mechanisms that ensure full
transparency and nancial accountability is extremely complex and may need
to be carried out gradually.
Affordability, sustainability, and water conservation
As stated above, a viable nancing strategy needs to be compatible not only

with existing institutional arrangements and available economic and nancial
resources, but also with the degree of community involvement and ownership
in the projects being nanced. Thus deep-rooted community ownership and
involvement should attract comparably strong and favorable nancing mechanisms and terms. Lessons from experience suggest that such deep-rooted ownership and involvement is realized when communities recognize their own contribution to the situation in which they nd themselves and resolve to assume
Chapter 9
Water charges
are powerful
instruments
for water
conservation
and demand
management
123
the responsibility and a leading role in addressing the problem. It is this awakening that sparks corrective community-led actions and provides a foundation
for strong community ownership and involvement.
The preceding discussion envisages that external nancing becomes necessary when nancial needs exceed the potential for domestic resource mobilization. Such nancing is not inconsistent with local ownership and community
involvement in water supply and sanitation projects. The use of grant-based
budget support for both capital and operation and maintenance for communities that are most off track in meeting the Millennium Development Goals is
the most robust way of making up the nancing gap. In the United States, for
instance, there was initially a 75 percent capital subsidy for sewage treatment
plant construction.
The main domestic sources of nancing are from households (in the form
of tariffs) and government (which comes from general and selective taxes).
Tariff levels have an impact on affordability, and therefore we strongly recommend lifeline tariffs, which help not only with affordability by the poor,
but also in reconciling affordability with the need to limit per capita water
consumption and generate adequate water revenues. Thus, water charges are
powerful instruments for water conservation and demand management. They
are also powerful instruments for making service providers responsive to user
preferences and needs.
What about middle-income countries?
So far, this chapter has focused on outlining a nancing strategy for low-income
countries that require external nance to be able to meet the Millennium Development Goals. Financing strategies for water and sanitation objectives in middle-income countries will differ substantially from the strategy outlined above.
As noted earlier, since middle-income countries have higher per capita
incomes and are able to devote larger shares of their GDP to meeting the Goals,
their total domestic resource mobilization generally exceeds annual nancing
needs for the Goalsin fact, middle-income countries that are able to devote
as much as 15 percent of GDP to meeting the Goals do not require any external
nancing. Moreover, middle-income countries are likely to require fewer public
investments to meet the Goals. As the example from Indonesia illustrated, the
number of unserved people in middle-income countries who are above the poverty line is often relatively signicant, facilitating cost recovery from users.
Financing strategies and modalities for middle-income countries will therefore differ from those for low-income countries in at least two ways. First, middle-income countries do not require external nancing to meet the Millennium
Development Goals and can typically access private capital markets for incremental resources. Second, middle-income countries have greater opportunities
to involve the private sector in nancing the water supply and sanitation goals.
Factors that facilitate the direct involvement of the private sector in nancing
124
Part 1
water supply and sanitation include the higher per capita income of households,
the higher rates of urbanization, the better trunk infrastructure, and of course
the stronger capital markets. (In the absence of these conditions, the private sector is unlikely to play a signicant role in nancing the water supply and sanitation target.) Of course, even in middle-income countries, signicant regional
and community disparities exist, and the government has a critical role to play
in facilitating national nancial policies that ensure equal access to services even
in traditionally neglected and economically depressed areas.
Water resources for all the

Chapter 10
Why does water resources

development and
management matter?
Sound water resources development and management underpins attainment of all the Millennium Development Goals, not only the one dealing
specically with water supply and sanitation. Moreover, it can avert tremendous human suffering (box 10.1). In this chapter and the two that follow it,
we discuss the links between water resources and the Goals (especially those
on poverty, hunger, health, gender, and environmental sustainability) and the
actions that countries will need to take to optimize the contribution of water
resources to the achievement of the Goals.
We use the term water resources development and management to mean
the actions required to manage and control freshwater to meet human and
environmental needs. Such actions include investments in infrastructure for
storage, abstraction, conveyance, and control, as well as for hydropower, ood
control, irrigation and drainage, water harvesting, and so on; investments and
actions undertaken to protect groundwater resources, control salinity, and promote water conservation; and an array of governance and management measures, including the development and strengthening of institutional and regu-
Box 10.1
Water-related
disasters:
facts from the
World Health
Organization
Source: WHO 2004a.
Almost 2 billion people were affected by natural disasters in the last decade of the
twentieth century, 86 percent of them by oods and droughts.
Flooding frequently leads to contamination of drinking-water systems with human
excreta from inadequate sanitation and with refuse and industrial waste from dumps.
Droughts cause the most illness and death, not only by limiting adequate water supply
but also by triggering and exacerbating malnutrition and famine.
Droughts and oods have broad economic impact: the Zimbabwe drought of the early
1990s was associated with an 11 percent decline in GDP; the recent oods in Mozambique led to a 23 percent reduction in GDP; and the drought of 2000 in Brazil cut
projected economic growth in half.
128
Part 2
Water can
act as a spur
to economic
development
Water resources for all the Millennium Development Goals
latory systems and policy reforms to promote wise stewardship of freshwater

resources.
Investments in water resources development and management can contribute to meeting the Millennium Development Goals as a whole both through
broad interventions designed to promote sustainable development in an area
such as multipurpose river basin development and aquifer managementand
through targeted actions addressing one or more particular goals in a specic
location, such as watershed management within degraded areas farmed by
poor families. Both types of interventions are important for making many of
the Millennium Development Goals a reality; indeed, holistic approaches to
water resources development and management can help to deliver the Goals
more cheaply and sustainably.
Table 10.1 illustrates some of the many ways in which the development,
management, and use of water affects the targets embodied in the Goals (see
Goals on p. xvi). The role of water resources development and management in
combating poverty and hunger, ensuring environmental sustainability, improving health, and reducing gender inequalities is analyzed in more detail below.1
Poverty and hunger
One in ve people on the planet, two-thirds of them women, live in extreme

poverty. Of the worlds 6 billion people, 2.8 billion live on less than $2 a day,
and 1.2 billion on less than $1 a day (DFID and others 2002). Chronic hunger,
among the starkest and most absolute manifestations of poverty, affects 800
million people. In this era of progress and plenty, 17 percent of the worlds
people are on the brink of starvation, and 11 children under the age of ve die
from malnutrition every minute.
In addition to the role that improving access to domestic water supply
and sanitation plays in reducing poverty, water can act as a spur to economic
Box 10.2
Improving water
management to
spur economic
development
Source: World Bank 2003.
Water infrastructure and sound water resources management can spur rural development. In Petrolina, in Northeast Brazil, water resources management and development
has created a large number of high-quality, permanent agricultural jobs (40 percent of
which are held by women). For every job in agriculture, two jobs have been created in
the supporting commercial and industrial sectors. These opportunities have reversed
the historic pattern of outmigration.
Experience has shown that cooperative programs for water resources management
have played an important role in regional integration and stability in Eastern Europe (the
Baltic Sea), Southeast Asia (Thailand and Laos), and South Asia (the Indus Basin).
Irrigation and drainage have contributed to past success in doubling food production,
forestalling famine, and reducing global food prices. Globally, irrigated areas represent
17 percent of the cultivated area, but account for 40 percent of food production. In
India, districts with little irrigation have a poverty incidence 2.5 higher than those with
substantial irrigation.
Chapter 10
Table 10.1
Contribution
of improved
water resources
management to
the Millennium
Why does water resources development and management matter?
Millennium
Development Goal
Poverty
To halve the
proportion of the
worlds people
whose income is
less than $1/day
Contribution of improved water resources management
Development Goals
Hunger
To halve the
proportion of the
worlds people who
suffer from hunger
129
Water is a factor of production in agriculture,

industry, and other economic activities.
Investments in water infrastructure and services are
a catalyst for local and regional development.
Reduced vulnerability to water-related hazards
reduces risks in investments and production.
Reduced ecosystem degradation makes livelihood
systems of the poor more secure.
Water is a direct input to irrigation for expanded grain production.
Reliable water sources support subsistence agriculture,
home gardens, livestock, and tree crops.
Reliable water sources support sustainable production of sh, tree
crops, and other foods gathered on common property resources
(also affects poverty when such goods are sold for income).
By helping to lower food prices, water
management can reduce urban hunger.
Primary education
To ensure
that children
everywhere
complete a full
course of primary
schooling
Improved water management reduces the incidence of such

catastrophic events as oods that interrupt educational attainment.
Gender equality
To ensure that
girls and boys
have equal
access to primary
and secondary
education
Community-based organizations for water management can

improve social capital of women by giving them leadership and
networking opportunities and building solidarity among them.
Child mortality
To reduce by
two-thirds the
death rate for
children under ve
Improved nutrition and food security reduces susceptibility to diseases.

Well-managed water resources help poor people make a decent living
and reduce their vulnerability to shocks, which in turn gives them more
secure and fruitful livelihoods to draw upon in caring for their children.
Malaria is a leading cause of death among children, and
better water management reduces mosquito habitats.
Major disease
To have halted and
begun to reverse
the spread of HIV,
malaria, other
major diseases
Environmental
sustainability
To stop the
unsustainable
exploitation of
natural resources
Slum dwellers
To improve the
lives of 100 million
slum dwellers
Improved water management in human settlements reduces

transmission risks of such mosquito-borne illness as
malaria and dengue fever. 1.2 million people die of malaria
each year, 90 percent of whom are children under 5.
Improved health and nutrition reduce susceptibility to and
severity of HIV/AIDS and other major diseases.
Improved water management, including pollution control and water
conservation, is a key factor in maintaining ecosystems integrity.
Development of integrated management within river
basis facilitates sustainable management of ecosystems
and mitigates upstream-downstream effects.
Biodiversity conservation and combating desertication
are furthered by sound water management.
Improved ood control and drainage in urban areas can
improve conditions in slum settlements, which are often built
on sites particularly vulnerable to water-related disasters.
development (box 10.2), and its role as a resource for agriculture, energy, and
industry is essential to ghting poverty and hunger. Water is an important
factor of production in a variety of industries crucial to economic development and poverty reduction; it is also central to the livelihood systems of the
rural poor. Meeting the Millennium Development Goal in this area will be
130
Part 2
Three points
of connection
stand out:
health,
livelihoods,
and
vulnerability
Box 10.3
Main water-related
recommendations
of the Millennium
Project for
meeting the
poverty and
hunger Goals
impossible without better water management and a dramatic expansion of

access to water for the worlds poorest (box 10.3). Ensuring an adequate food
supply, achieving aggregate progress against poverty at the national level, and
relieving poverty at the community and household levels simply cannot occur
in many parts of the world, given current water shortages. Clearly, therefore,
insufcient water blocks overall economic growth.
For the poor much more than for the nonpoor, the fulllment of humankinds most basic aspirations, such as living a long and healthy life, having
sufcient resources to earn a living, and seeing ones children reach adulthood,
is predicated on the state of the environment, including water resources. Environment is central to poor peoples sense of well-being, empowerment, and
control over their own lives. Three points of connection between poor people
and their water environment stand out: health, livelihoods, and vulnerability.
Health. The health of poor women and men is disproportionately
affected by contaminated water and poor sanitation services, setting up
a cycle of ill-health and further impoverishment that has severe nancial and personal costs.
Livelihoods. In rural areas, poor peoples livelihood systems are rooted
in the natural world and depend upon ecosystem health. Contamination of common property resources, such as lakes, rivers, and coastal
areas, directly translates into less food, income, and time for the poor.
Common property resources provide a signicant share of food and
household income for the poorest families.
Vulnerability. Vulnerability is a critical dimension of poverty. Poor
women and men are particularly at risk from environmental shocks and
crises. Increasingly frequent and severe natural disasters (cyclones, hurricanes, oods, landslides, and droughts), as well as changes in rainfall
patterns, shifting agricultural zones, and rising sea levels impact developing countries and the poor who live there disproportionately. The
poor are the most affected by environment-based conicts, which are
Target 1 on poverty
Increase public investment in basic human needs, including water and sanitation, to
foster a productive labor force that can participate effectively in a global economy.
Task Force on Hunger
Increase agricultural productivity of food-insecure farmers, with a special focus on
small-scale water management.
Improve nutrition of the vulnerable (water-related diseases are a leading cause of
diarrhea, which hinders the bodys ability to absorb nutrients).
Restore natural assets of food-insecure people, including water resources (lakes
with sh, for instance).
Chapter 10
Poor water
management
practices
worsen
the water
shortages
in many
countries
131
also becoming more frequent. Extreme events can have a strong impact
on the ability of many developing countries, especially in the tropics, to
achieve the Millennium Development Goals. Damage caused by oods
and droughts and other extreme climate events can undo, in a short
period, many years of steady development and growth. Although such
extreme events start with direct damage to infrastructure and crops,
they often ripple through many areas of economic activity, leading to
widespread macroeconomic, nancial, and political consequences. In
Kenya, for example, ooding during the El Nio event of 199798 is
estimated to have cost some $880 million (10 percent of GDP) through
the loss of roads, pipelines, and water treatment plants (Mogaka and
others 2002).
The bulk of the worlds poorest people, 800 million to 1 billion rural people, live in arid areas and depend directly on natural resources, including water,
for their livelihoods (Dobie 2001). Many drylands people are subsistence farmers who also keep some livestock, while others are pastoralists, a nomadic way
of life that is increasingly under threat. In dry, rural countries, such as Mali
and Eritrea, most of the population lives this way, whereas in countries with
both humid and dry regions, the dry areas are home to the poorest of the poor
(Dobie 2001).
Retaining as much water as possible is a question of survival, but in arid
areas a substantial amount of rainwater is lost through surface runoff, evaporation, and percolation. When the rains come and the water runs off, topsoil is
carried away, gullies are formed, and the water is lost. People in drylands are
uniquely vulnerable not only to drought and other natural disasters, but also to
economic and social changes. Achieving sustainable development in the drylands has signicant implications for reducing poverty and hunger globally.
Agriculture is now and will continue to be a key sector for low-income
countries and the poor who live there. In developing countries, 80 percent of
export earnings come from the agriculture sector. It is also the thirstiest sector:
irrigated agriculture accounts for almost 70 percent of the global freshwater
use. Limited and unreliable access to water is a determining factor in agricultural productivity in many regions, a problem rooted in rainfall variability that
is likely to increase with climate change.
Today, underperforming irrigation systems and poor water management
practices worsen the water shortages that already exist in many countries.
Irrigation and poor drainage lead to salinization and waterlogging. Excessive extraction for irrigation has lowered water tables to critical levels in many
places. The use of pesticides and fertilizers in agriculture pollutes groundwater.
Invasive species have covered huge water areas throughout the world, clogging
irrigation channels, threatening infrastructure, and leading to the collapse of
sheries.
132
Part 2
Most
irrigation
systems are
nancially
out of reach
for poor
smallholders
The return to water in food production, including the efciency of agricultural water use, can be improved substantially through better water resources
managementand provide more crop per drop. Clearly this is necessary to
meet the hunger target; it is also critical in terms of the contribution increased
grain production can make to the economy as a whole, and thus to meeting the
poverty eradication Goal.
Projected increases in the worlds population will lead to greatly increased
demands for food, primarily from developing countries. Currently, the 17 percent of the worlds cultivated land that is under irrigation produces 40 percent
of the worlds food (FAO 2003). Much of the projected increased demand for
food will have to come from improved and expanded irrigation, but this will
be only a partial solution. Most irrigation systems are nancially out of reach
for poor smallholders. Most food demand for poor people will come from areas
where investment in irrigation makes no sense, with too little return from the
signicant capital needed. The major part of the crops produced worldwide is
still grown in rain-fed agriculture, and to improve the livelihoods of the farmers in the developing world more emphasis must be put on employing practices
that ensure higher yields per water input.
Water is also a factor of production in industry and many other types of
economic activity, including both large-scale activities and small, often homebased activities where the poor are entrepreneurs, such as food processing for
vending in markets. Access to key factors of production, including water, is
critical to the viability of activities that can serve as a ladder out of poverty. In
some cases, investments in water infrastructure, such as dams and irrigation
schemes, can act as a catalyst for local and regional development.
Water can be critical in supplying energy services to unserved poor women
and men in rural areas, and safe, environmentally friendly, and affordable
energy services are critical to poverty reduction. Energy services that allow
for heating, cooking, and illumination are not only a boon to the activities of
daily life; they are also critical inputs to agriculture and the types of small-scale
productive activities that are a signicant component of the rural economy in
poor areas.
In sum, water is critical in achieving the Goals on poverty and hunger
because:
Agriculture is and will continue to be a key sector for low-income countries and the poor who live there.
Water is a factor of production in industry and many other types of
economic activity.
Common environmental resources provide a signicant share of food
and household income for the poorest families, and the livelihood systems of poor women and men depend upon a healthy environment.
Pollution of common resources, such as lakes, rivers, and coastal areas,
directly translate into less food, income, and time for the poor.
Chapter 10
Water is
perhaps
the most
fundamental
of all
environmental
resources
133
Sound water management may reduce the incidence of a range of other

diseases for which water is a vector.
Environmental sustainability
The overall Millennium Development Goal of ensuring environmental sustainability (Goal 7) has three specic targets:
Target 9: Integrate the principles of sustainable development into country policies and programs; reverse loss of environmental resources.
Target 10: Reduce by half the proportion of people without sustainable
access to safe drinking water and basic sanitation.
Target 11: Achieve signicant improvement in the lives of at least 100
million slum dwellers by 2020.
Clearly, water is a key dimension in achieving each of these three targets.
Target 9 on sustainable development
Water is perhaps the most fundamental of all environmental resources and
the most critical for the viability and long-term sustainability of the worlds
ecosystems (box 10.4). Ecosystem health, in turn, is critical for the quantity
and quality of water supply. Human activities, such as infrastructure development, modication of river ows, land conversion (for example, deforestation),
increased agricultural production, overshing, introduction of exotic species,
and release of pollutants, upset the delicate balance between water resources
and environmental sustainability.
Several threats to overall ecosystem health, and consequently to the ability of ecosystems to provide the services upon which human life depends, are
particularly relevant to water resources.
Climate change and resulting alterations in weather patterns, water distribution, and sheries will seriously affect marine ecosystems and small
island developing states, and will also threaten poor populations unable
to protect themselves from ooding, erosion, water shortages, and coral
bleaching.
Box 10.4
Main water-related
recommendations
of the Millennium
Project Task Force
on Environmental
Sustainability
Institute integrated water resources management using an ecosystem-based

approach.
Invest in improving the water efciency of cropping systems.
Invest in wastewater treatmentparticularly in urban areas.
Improve environmental monitoring, indicators, assessment, and use of information
in decisionmaking.
Remove environmentally damaging subsidies in water use and sheries.
Protect critical land and marine ecosystems.
Strengthen institutional capacity for integrated ecosystem management.
134
Part 2
Poor slum
dwellers have
little way
to insulate
themselves
from threats
Loss of species diversity and genetic diversity within species impacts the
health of marine and coastal environments, as well as that of wetlands.
Global sheries, marine ecosystems, and coastal habitats are quickly
degrading because of overshing and contamination from land-based
activities.
Freshwater ecosystems are being damaged by runoff, silting, fertilizers,
pollution, and invasive species.
Drylands are further degrading as a result of desertication, dropping
water tables, and overirrigation.
It is important to note that target 9 is intended to address the goal of
stopping the unsustainable exploitation of water resources by developing
water management strategies at the regional, national, and local levels, which
promote both equitable access and adequate supplies, which was clearly
enunciated in the Millennium Declaration, but is not referred to explicitly or
implicitly in any other of the eighteen Millennium Development targets.
This is, of course, the Millennium Development target on water and sanitation that was discussed at length in previous chapters. Although clearly this
target is much more than an environment target, given its implications for
human health and poverty reduction, ofcially it resides with the overall Goal
of ensuring environmental sustainability.
Target 11 on improvements for slum dwellers
For poor people living in slums, the water-related problems already discussed
in relation to the other Millennium Development Goalsinadequate access to
clean water and sanitation services; poorly managed water resources; and the
resulting drain on human health, education, womens empowerment, and environmental sustainabilityare magnied (box 10.5). The geographical concen-
Box 10.5
Living with urban
environmental
problems
We are eight people living in a small one-room shack where we have to sleep in shifts.
There is a public toilet down the lane, but we have to queue for two hours. The toilet is
broken, sewage owing everywhere. Several girls have been molested there, and some
even raped, in broad daylight. My sisters and mum dont go there. We keep our business
for the evenings. In the dark we wrap it into plastic bags and throw it as far away as possible. These are our ying toilets, and our neighbors do the same. We know its not right,
so we do this only at night. Our tummies sometimes hurt the whole day, since we just
have to hold. When it rains, the ying toilets [together with the contents] get washed with
the rainwater and accumulate on the door. The feces stay there for days. When the rains
are heavy, it gets washed right into the house. We have no hope of leaving here. We dont
have anywhere else to go.
Halima, a Nubian girl from Kibera, Nairobis largest slum, home to 700,000 people
Chapter 10
Management
of water
resources
more
generally has
signicant
health
impacts
Box 10.6
Main water-related
recommendations
of the Millennium
Project Task Force
on Improving
the Lives of
Slum Dwellers
135
tration of people, production, and pollution in slums amplies the biological

pathogens and chemical hazards to which urban people are exposed. Poor slum
dwellers, unlike their wealthier urban counterparts, have little way to insulate
themselves from these threats. They are exposed to a host of environmental
risks because they live in poor housing, often built in hazardous locations (such
as industrial sites or ood-prone areas). Poor urban dwellers are also frequently
outdoors, because they generally face long commutes, often work as laborers or
street vendors, and frequently ee their overcrowded houses. As a result, morbidity and infant mortality rates are higher among slum dwellers than among
urban people who do not live in slums, or among the rural population (UNHABITAT 2003).
As the Bruntland Commission noted more than 15 years ago, the future
will be predominantly urban, and the most important environmental concerns
of most people will be urban ones (World Commission on Environment and
Development 1987). Two-fths of people in Africa, Asia, the Pacic, Latin
America, and the Caribbean now live in urban areas, and every passing day
further swells the ranks of city and town dwellers. UN-HABITAT estimates
that more than 900 million people in the developing world live in slums. In
least developed countries and Sub-Saharan Africa, more than 70 percent of the
urban population lives in slums, a gure expected to increase (UN-HABITAT
2003).
Tackling urban environmental problems is critical to meeting the Millennium Development target of improving the lives of 100 million slum dwellers
(box 10.6). The main challenge is addressing threats to health, livelihoods, and
security stemming from hazardous living conditions and poor services; these
threats include substandard housing, polluted water, lack of sanitation and
solid waste systems, outdoor air pollution from industry and trafc, indoor air
pollution from low-quality cooking fuels, and extreme vulnerability to environmental disasters (which are likely to increase with climate change). Many
steps taken to reduce environmental hazards, such as building with better
materials and ensuring adequate drainage systems, also contribute to disaster
preparedness, as does improving urban planning and zoning so that the poor
are not relegated to ood-prone or otherwise unsafe living sites.
Promote citywide slum upgrading including the provision of infrastructure services
for water and sanitation.
Provide alternatives to slum formation by making land and basic infrastructure
available for low-income housing.
Invest in urban trunk infrastructure, including for water and sanitation.
Ensure that water tariffs are affordable for poor people.
Improve solid waste disposal and provide investments to lower the pollution of
water and air.
136
Part 2
Vector-borne
Health
diseases are
Over and above the impact of domestic water supplies and sanitation on human
health, the management of water resources more generally has signicant health
impacts in terms of vector-borne diseases and water contamination. Worldwide, more than 160 million people are infected with schistosomiasis,2 which
causes tens of thousands of deaths each year; there is a 77 percent reduction
in schistosomiasis from well-designed water supply and sanitation interventions (WHO 2004a). Human-built reservoirs and poorly designed irrigation
schemes are the main drivers of schistosomiasis expansion and intensication.
Malaria kills more than one million people each year, 90 percent of them in
Africa, the great majority of them children. Along with HIV/AIDS, malaria
is one of the major public health scourges eroding development in the poorest
countries in the world, and costs Africa more than $12 billion annually. It has
slowed economic growth in African countries by 1.3 percent a year, the compounded effects of which are a gross domestic product level now 32 percent
lower than it would have been had malaria been eradicated from Africa in 1960
(WHO 2004b).
Vector-borne illnesses, which include malaria (box 10.7), dengue, and
schistosomiasis, are passed to humans by insects and snails that breed in
aquatic ecosystems (UN/WWAP 2003). Vector-borne diseases are becoming
more difcult to treat because of the growing resistance of bacteria to antibiotics, parasites to other drugs, and insects to insecticides. Thus, improved water
management practices are becoming an increasingly important tool in combating this category of disease. For instance, improving irrigation techniques
to avoid standing or slow-moving water can have a big impact on the breeding
of mosquitoes that carry malaria. Improved disposal of household wastewater
can also eliminate a choice breeding ground for mosquitoes.
Persistent organic pollutants, or POPs, are another danger as a source of
water contamination. POPs are produced and released into the soil, air, and
water by human activity, such as irrigation, industrial discharges, and improper
waste disposal. Derived from pesticides, other agrochemicals, industrial chemicals, and the byproducts of industrial processes, they can accumulate in living
organisms to levels harmful to both human and environmental health. They
include such substances as dioxin, PCBs, and DDT.
becoming
more difcult
to treat
Box 10.7
Malaria: facts
from the
World Health
Organization
Source: WHO 2004b.
Some 1.2 million people die of malaria each year, 90 percent of whom are children
less than 5 years old.
There are 396 million episodes of malaria every year; most of the disease burden is in
Sub-Saharan Africa.
Intensied irrigation, dams, and other water-related projects contribute signicantly to
this disease burden, and better management of water resources reduces transmission
of malaria and other vector-borne diseases.
Chapter 10
Management
of water
resources has
signicant
gender
dimensions
137
Research suggests that the rural and urban poor, who are most exposed
to environmental hazards, and especially women, children, and infants, are
generally the groups most affected by POPs. Evidence points to links between
human exposure to specic POPs and cancers and tumors, learning disorders
and changes in temperament, immune system changes, reproductive disorders,
birth defects, a shortened period of lactation in nursing mothers, and diseases
such as endometriosis and increased incidence of diabetes, among others. These
substances appear to become highly concentrated in human tissue and breast
milk and can be passed to the developing fetus through the placenta. Even in
small amounts (parts per trillion) these substances can have serious impacts
on the development of the brain and reproductive system of children (CIEL
website). These substances become integrated into the food chain, prolonging
their damaging effects on ecosystem and human health.
Gender equality
In addition to the gender implications of improving access to domestic water supplies and sanitation, as described in part 1, the management of water resources
more generally has signicant gender dimensions (box 10.8). For example:
Rural women produce 60 percent to 80 percent of food in developing
countries, and their contribution to food security is likely to increase
because of the feminization of agriculture, which results when rural
men migrate to urban areas in search of paid work and women remain
to farm and care for family members. Womens role as farmers is frequently overlooked by agricultural extensionists, including those working for irrigation agencies; they often exclude women from access to
water (for instance, by requiring land titles for access to irrigation systems). Explicitly involving women farmers in irrigation schemes and
giving them a voice in decisionmaking processes related to water management is essential to ghting rural poverty. Also helpful would be
including other ways women use irrigation water, such as in home-based
cottage industries and home gardens, in water development and management plans (Molden and de Fraiture 2004).
Box 10.8
Main water-related
recommendations
of the Millennium
Project Task Force
on Education and
Gender Equality
Provide incentives to keep girls in primary and secondary school.

Invest in gender-sensitive infrastructure such as girls toilets, without which many
girls drop out of school.
Invest in gender-responsive infrastructure, that is, infrastructure that reduces
the time poverty of women and girls, such as infrastructure for water supply and
sanitation.
Protect womens property and inheritance rights, to which access to water is often
linked.
138
Part 2
There are
positive
reinforcements among
the Goals,
as well as
downward
spirals
Social and economic analyses, including documenting natural resource

uses, are incomplete without an understanding of gender differences and
inequalities. With gender analysis, planners gain a more accurate picture of communities, natural resource uses, households, and water users.
Understanding the differences between women and men (who does what
work, who makes which decisions, who uses water for what, who controls
which resources, who is responsible for the different family obligations) is
part of a good analysis and can contribute to more effective initiatives.
Without specic attention to gender issues, initiatives and projects
can reinforce and even worsen inequalities between women and men.
Although many initiatives are thought to be gender neutral, they
rarely are. Projects and programs often bring new resources, such as
training, tools, and technology. Whether someone is male or female
can inuence whether he or she can take advantage of these opportunities, and even projects aimed at women can be captured by men when
signicant new resources are at stake.
The involvement of both women and men in integrated water resources
initiatives can increase project effectiveness. Experience shows that
ensuring both womens and mens participation can enhance project
results and improve the likelihood of sustainability. In other words, a
project is more likely to achieve what planners hope it will achieve if
women are active participants and decisionmakers.
In addition, even water-related environmental challenges affect women
more negatively than men. For example, studies in Bangladesh show that
women suffered most following the 1991 cyclone and ood. Among women
ages 2044, the death rate was 71 per 1,000, compared to 15 per 1,000 for
men. The reasons: women were left at home by their husbands to care for
children and protect property; their saris restricted their mobility; they were
malnourished and thus physically weaker than men; and during the cyclone,
the lack of purdah (partitions used to separate women from men or strangers)
in public shelters may also have deterred women from seeking refuge (Baden
and others 1994).
Exploiting potential synergies through combined approaches
There is a fundamental synergy between the various Goals.3 It is difcultif

not impossibleto make progress on a few Goals without progress on the others. There are positive reinforcements among the Goals, as well as downward
spirals. Malnourished people are more susceptible to diseases, such as diarrhea,
and diarrhea in turn saps the body of calories and micronutrients. Healthy,
well-fed people have more energy to escape from poverty. Safe drinking water
near home keeps more girls in school, and educated girls have better nourished
children, even without an increase in income. Poor, malnourished people are
more likely to mine their natural resources for short-term benets, regardless
Chapter 10
Countries
should avoid
actions that
focus singlemindedly on
one target at
the expense
of another
139
of the long-term cost. Environmental degradation and polluted water affect

the poor rst. Healthy, well-nourished people with a decent income prioritize
protection of their environment and natural resources. Conservation of natural
forests provides famine foods to prevent malnutrition during periods of crop
failure. Rehabilitation of degraded soil and water resources reduces the risk of
crop failure and shortens the preharvest hunger period.
A critical challenge for meeting the Millennium Development Goals,
therefore, is to dene and promote strategies that will contribute to multiple
Goals, and avoid strategies that create conicts among them. Independent
sectoral planning will increase the total cost of achieving the Goals, reduce
effectiveness, and make it hard for communities to plan and manage multiple
programs. Achieving the Goals will require political consensus and mobilization across many constituencies; integrated and synergistic strategies are more
likely to generate enthusiasm and reduce costs of conict. While exploiting all
possible synergies, countries should also actively avoid water resource development and management actions that focus single-mindedly on one target at the
expense of another.
Six key synergistic approaches that involve the planning, development,
management, and use of water are:
Disseminate small-scale water technologies for livelihoods. These technologies provide livelihoods to small and landless farmers, while addressing the hunger and environment goals (Rijsberman 2004). An array of
technologies is available, appropriate to a variety of agroclimatic and
socioeconomic conditions, ranging from rainwater harvesting in dry
areas to the use of manual pumps to access shallow groundwater. What
needs to be recognized is that successful adoption by a large number of
people depends less on the exact nature of the technology itself than on:
(a) the social marketing of the technology; (b) the availability of microcredit programs; (c) the institutional support through nongovernmental
networks or community-based organizations to provide training and
technical support; and (d) the community and household preferences.
Reduce the vulnerability of communities to water-related natural disasters through land reform, infrastructure construction for water storage
and ood protection, and improved land use planning, including slum
upgrading. These changes would address poverty, hunger, and health
goals by increasing incomes and reducing the domestic and production
risks faced by poor households.
Invest in water and sanitation systems, including new infrastructure for
water management, in support of the nutrition, health, and environment
Goals. Investments in water supply and sanitation services will contribute to the achievement of public health, poverty, and hunger Goals.
Infrastructure investment creates both temporary and permanent job
opportunities, contributing to poverty alleviation.
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Win-win
approaches
are highly
desirable but
not always
possible
Invest in community-based natural resource management, including urban

agriculture, for hunger, poverty, and environment Goals. This might
involve investing in community sheries conservation strategies to
reduce hunger in sher and sh-consuming populations and to achieve
marine conservation objectives; strengthening resource tenure and
building the capacity of forest communities for joint conservation and
rehabilitation, as well as sustainable commercial use; and investing in
community herding systems that jointly address livestock, rangeland,
and wildlife management with a view to protecting and enhancing the
livelihoods of poor, rangeland-dependent communities. This might
involve supporting urban and periurban small-scale agriculture, livestock, and forestry to jointly address tenure, water, food access, micronutrient malnutrition, and poverty goals.
Develop new sanitation technologies to use wastewater for periurban agriculture. This development would address a key aspect of the sanitation
Goal by turning the challenge of dealing with urban wastewater into
an opportunity, a resource for generating additional livelihoods. It also
addresses the poverty and malnutrition Goals for one of the most vulnerable groups of very poor people, those living in the periurban areas,
the slums, of medium-to-large cities in developing countries. The Food
and Agriculture Organization has estimated that 20 million hectare are
directly or indirectly4 irrigated with wastewater in 50 countriesclose
to 10 percent of the total irrigated area (UN/WWAP 2003).
Improve terms of agricultural trade. Trade creates markets for agricultural
products, thus enabling investment in more efcient water use. In an
increasing number of developing countries, irrigated agriculture can be
a key to export-led economic growth, as illustrated by the experience of
Chile and South Africa. A change in global trade regimes and the opening up of markets by industrialized countries would greatly enhance
the opportunities for such growth, which, if supported by appropriate
macroeconomic policies, would also provide strong incentives for more
efcient water use. Furthermore, trade in agricultural products and in
virtual water,5 as governed by the World Trade Organization, has
important ramications for the availability of water resources in many
countries.
Although win-win approaches that advance more than one Millennium
Development Goal simultaneously are highly desirable, they are not always
possible. Indeed, there are many situations in which tradeoffs among the
Goals are inevitable, particularly in the short term. Initiatives designed to spur
economic development, for example, can come into conict with the need to
protect the quantity and quality of water. Cutting down trees for rewood
or income-generating activities can contribute to deforestation, which eventually affects both rainfall and siltation of streams and rivers. Development of
Chapter 10
141
small dams to enable dry-season irrigation by smallholders can increase suitable breeding places for malaria mosquitoes and snail vectors of bilharzia or
schistosomiasis. Pollution from industrial or agricultural activities designed to
generate livelihoods and reduce poverty can greatly affect water quality. Irrigation and poor drainage can lead to salinization and waterlogging, negating
the intended improvements in agricultural productivity. Excessive extraction
of groundwater for irrigation can lower water tables to critical levels, which
may deplete drinking-water supplies for the poor. Sewerage systems that
solve environmental problems and avert health crises in one area can create
environmental problems elsewhere, if the untreated sewage is dumped into
another communitys water source. As all these examples demonstrate, careful
analysis and coherent management is called for to keep improvements in one
area from having negative effects in another.
Chapter 11
What actions are needed?
Whereas investments in water resources development and management

contribute in a variety of ways to meeting the Millennium Development
Goals as a whole, the specic water-related interventions required to meet the
Goals will vary across regions, countries, and even subnational areas. Context
strongly inuences the nature of the water resources actions that must be taken
to meet the Goals.
The key determinant across virtually all regions and scales of analysis is
the relationship between the availability of freshwater and the requirement for
its use. Both availability and requirement are multidimensional notions, each
having quantitative, qualitative, temporal, and spatial dimensions. Simply put,
the actions needed to meet the Millennium Development Goals in a given case
depend on the extent to which the availability of water resourcesin its many
dimensionsis adequate to meet the requirement for water resources to meet
the health, poverty, gender, and environmental sustainability objectives of the
Millennium Development Goals.
The availability of freshwater resources can be disaggregated into three
principal dimensions: quantity, quality, and variability.
The quantity of water available, from both surface and groundwater
sources, is one fundamental aspect of availability. This amount is, of
course, strongly related to rainfall and to the infrastructure already
in place for water storage and abstraction. Availability comprises both
physical access to sources wholly within a particular boundary (including fossil groundwater) and negotiated access to shared water sources,
such as rivers, lakes, and aquifers.
Quality is an aspect of freshwater availability that has become a major
issue in some parts of the world, and that can also have a major impact
on attainment of the health and environmental sustainability Goals. In
Chapter 11
Tradeoffs will
need to be
made in the
use of water
resources
to meet the
various Goals
143
some cases, such as Bangladeshs problem with arsenic-contaminated

groundwater, water quality problems are naturally occurring. Much
more common, however, is the degradation of water quality by anthropogenic causes, such as pollution discharges into surface water bodies
and leaching of contaminants into underground water sources.
Variability in the availability of water, both in time and space, depends
both on climatic variables and on the types of infrastructure and management arrangements already in place for water control. Surface waters
often have highly seasonal regimes; this is particularly the case in the
tropics, where most of the countries that are off-track in meeting the
Goals lie. In addition to seasonal variability, there is often considerable
variability from one year to another. Both seasonal and year-to-year variability create a need for diversication of water sources, early-warning
systems, contingency plans for droughts and oods, and storage alternatives (both surface and subsurface).
The requirement for freshwater resources not only has quantity, quality, and
(spatial and temporal) variability characteristics, but also goal-specic dimensionswhich mean that the nature of the water resources actions needed to meet
the Millennium Development Goals will vary from Goal to Goal. For example,
to meet the poverty Goal, countries will need to use water for productive purposes
to ensure livelihoods in water-dependent sectors, such as agriculture, industry,
energy, transport, and sheries; they will also need to control water variability,
since households living at the brink of survival can easily be devastated by a single water-related extreme event, such as a ood or drought. Meeting the hunger
Goal will require the use of water as an input to agriculture and to support productive activities that help ensure economic access to food (for example, through
employment of landless labor in the dry season), as well as access to safe water
and adequate sanitation to maintain the health conditions required for proper
absorption of nutrients. Meeting the health Goals will require access to domestic
water availability and sanitation, sound water management to limit vector-borne
diseases, and appropriate levels of water quality. Meeting the gender Goal will
require ensuring that women have a strong voice in decisionmaking processes
related to water management. Meeting the environment Goals will require that
sufcient amounts of water are reserved to ensure healthy ecosystem functioning.
It is, however, important to note that the Millennium Development Goals will
not be addressed in isolation. Typically, other usesagricultural, municipal, and
industrialdominate water management activities and need to be addressed to
ensure that the Millennium Development Goals receive priority.
All this will greatly affect the level and the nature of requirements for water,
the stress on water resources, and the mechanisms for identifying and ensuring
its best usethe actions needed to meet the Millennium Development Goals.
Unfortunately, in many of the worlds poorest countries, the quantity, quality,
and variability of water resources is such that tradeoffs will need to be made in the
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Countries
that start
from behind
can overcome
these
constraints
use of water resources to meet the various Goals, particularly between the hunger
and environmental sustainability Goals. According to a recent study conducted
under the Comprehensive Assessment of Water Management in Agriculture,
sponsored by the Consultative Group on International Agricultural Research
(CGIAR), more than 1.4 billion people already live in river basins where high
water-use levels threaten freshwater ecosystems (Smakhtin and others 2004).
Other studies have shown that in order to sustain ecosystems, irrigation withdrawalsvitally needed to meet the hunger Goalswill need to be reduced by
7 percent by 2025, in comparison with 1995 levels (Alcamo and others 2000).
Clearly, innovative approaches will be required to reduce these inherent tradeoffs
among the uses of water resources to meet the various Goals.
A quick picture of this situation is provided in map 11.1, which depicts water
stress in major basins, taking into account environmental water requirements
(Smakhtin and others 2004). The map uses a water-stress indicator that relates
total withdrawals to the mean annual ow less an estimated amount for environmental ow. Much of the area under greatest stress, where people are already
overexploiting rivers by tapping water that should be reserved for environmental
ows, coincides with areas that are heavily developed for irrigation to provide
water for food. Much of Sub-Saharan Africa and Latin America has low degrees
of environmental water stress, raising the issue of whether these areas could be
tapped for additional water to support livelihoods, if that could be done sustainably. Note that areas with high levels of water stress do not coincide with areas
with low levels of access to safe drinking water or basic sanitation.
The preceding analyses suggest two important conclusions:
First, the specic actions that a particular country or region should take to
improve water resources management depend on the relationship between the
availability and requirement for water resources, as well as the socioeconomic,
political, and historical circumstances of that area. Clearly, natural endowments give countries and regions different starting points for water resources
development and management. But countries that start from behindwith
high variability and low per capita freshwater availabilitycan overcome these
constraints through appropriate investments and management arrangements.
Second, given the complex relationship between water resources and poverty, hunger, gender equity, and environmental sustainability, coordinated
water management will have to be a fundamental component of any national
strategy to attain the Millennium Development Goals. In particular, planning
and policy development based on the Goals must be supported by an integrated approach to land, water, and ecosystems, one which conforms broadly
to the recommendations from the Johannesburg Summit regarding integrated
water resources management and water efciency strategies. Meeting the Millennium Development Goals will therefore require investing in water resources
development and management and adopting an integrated water resources
management approach, as outlined below.
Map 11.1

Note: High water stress indicates that the amount of water withdrawn for human use is a large share of the amount available after environmental requirements are met. In most basins with a water stress
indicator of 0.7 or higher, aquatic ecosystms are already suffering some degree of degradation, and there is little or no scope to increase water withdrawals without causing irreversible damage
Source: Smakhtin and others 2004.
Water stress in major

river basins
Chapter 11
145
146
Part 2
Countries
will need to
embark on a
plan of action
involving
both supply
and demand
management
Investing in water resources development and management
As the challenges for sound water resources management vary within and
among countries, so must the strategies for identifying and addressing waterrelated obstacles to achieving the Millennium Development Goals. In general,
however, countries with high variability or low availability in relation to freshwater requirements will need to embark on a plan of action involving both
supply and demand management. A coherent approach to investing in water
resources infrastructure and management to meet the Millennium Development Goals in a particular country might include:
Identifying intermediate water resource targets that support each of the key
Millennium Development targets. In the case of the hunger target, for
example, a short-term water-related target might be an estimate of the
land area that would need to be brought under irrigation or the degree
of investment required to improve the efciency of existing systems. For
both the poverty and the hunger targets, an intermediate water target
might be a calculation of the storage capacity and early warning systems
that would be needed to effectively control oods and droughts.
Intermediate targets for water resources should address both investment
and management issues, taking into account the vast deciencies in
infrastructure endowments in the countries farthest from reaching the
Goals, as well as the potential for demand management. Intermediate
targets will need to include both a physical dimensionfor example, the
need for irrigation infrastructure in working orderas well as a concept
of usefor example, whether communities and local governments are
able to maintain a safe, reliable supply of water from a tube well.
Carrying out needs assessments for water resources development and management based on intermediate targets. Governments should determine the
infrastructure development, watershed management practices, demand
management systems, and institutional and policy measures needed
for meeting the Millennium Development Goals, as well as the human
and nancial resource requirements to achieve them. They should cost
out these needs, including both capital and operation and maintenance
costs. The water infrastructure considered should include all hydraulic
infrastructure needed to align water supply with demand, from water
storage and irrigation infrastructure to interbasin water transfers and
infrastructure for industrial and other economic uses. Such costs should
also include investments needed to ensure that infrastructure development does not negatively impact any of the Millennium Development
Goals, especially the environmental sustainability targets. Equally
important, estimates of the resources necessary to ensure proper, sustainable functioning of installed infrastructurefor example, through
training and institutional capacity-building programsshould be
included in such assessments.
Chapter 11
Water
resources
development
and
management
should be
integrated
147
Developing a plan that outlines how to meet the needs identied in the
assessment and how such actions will be integrated into a national poverty reduction strategy based on the Millennium Development Goals. This
would entail mapping out, with specic milestones at national and
subnational levels, the year-to-year actions and investments required to
meet the needs identied in the assessment. Such plans should not be
stand-alone sectoral documents, but elements that will be integrated
into overall strategies to reduce poverty and promote sustainable development in line with the Goals.
Dening and promoting strategies that will contribute to multiple Goals,
and avoiding strategies that create conicts among them. A coherent
national planning process should guide sectoral planning. The absence
of coherence may increase the total cost of achieving the Millennium
Development Goals, reduce effectiveness, and make it hard for communities and subnational governments to plan and manage multiple
programs. Integrated and synergistic strategies that generate buy-in
from all stakeholders and reduce costs and conict should be given
priority. This is not to advocate rigid central planning; what is recommended is a coordination of sectoral activities in such a way that
promotes synergies among them, rather than attempts to plan entire
national economies.
Adopting integrated water resources management
Because the Millennium Development Goals are interlinked, water resources

development and management in support of the Goals should be pursued in an
integrated manner, with priority given to actions that further multiple goals.
Integrated water resources management (IWRM), as dened by the Global
Water Partnership, is a process that promotes the coordinated development
and management of water, land, and related resources, in order to maximize
the resultant economic and social welfare in an equitable manner without compromising the sustainability of vital ecosystems.1 Integrated water resources
management builds on three basic pillars: an enabling environment of proper
water resources policies and legislation; an institutional framework of capable
institutions at national, local, and river-basin levels; and a set of management
instruments for these institutions. Of course, the form that IWRM will take
must vary from country to country; in some cases, groups of neighboring
countries may protably engage in joint IWRM exercises.
IWRM focuses on development (investment), as well as management
issues. This approach is particularly important for the poorest countries most
at risk of failing to achieve the Millennium Development Goals, where deciencies in infrastructure endowments are vast. The target set by the World
Summit on Sustainable Development in Johannesburg for countries to develop
IWRM and water efciency strategies by 2005 provides an opportunity to
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Part 2
Integrated
development
will need to
recognize the
challenges of
sharing water
between
countries
infuse planning processes based on the Millennium Development Goals with

consideration of water resources (GWP 2004). If properly designed, these
national IWRM strategies and processes can establish an enabling framework
that encourages water management and services that benet the poor, and thus
advance the Goals.
At the same time, the 2005 IWRM target included in the Johannesburg
Plan of Implementation should be interpreted as meaning the initiation of
a robust water resource management process. For example, one meaningful
measure of progress toward a national IWRM process would be that representatives of all stakeholder groups have had the opportunity to discuss the necessary compromises between competing interests in water. Such processes take
time, and the IWRM activities initiated in anticipation of the 2005 milestone
should be considered essential rst steps in a much longer journey toward sustainable water resources management.
Experience in several countries suggests that IWRM is an effective way of
coordinating development strategies across sectors and geographical regions.
Uganda and Burkina Faso have gone through multiyear IWRM processes
resulting in new national policies, strategies, and laws for their water resources
development and management. China, India, Thailand, and Nicaragua refer
to their policy reform processes as IWRM-based.
The integrated development and management of water resources in support
of the Millennium Development Goals in countries sharing transboundary
water resources will need to recognize the challenges of sharing water between
countries. Transboundary considerations, however, should not be viewed simply as an additional level of integration; they can also be a potential catalyst
for the development of more effective approaches to reaching the Millennium
Development Goals.
Examples of context-specic actions
Ultimately, context should determine the specic actions and strategies a country should use to reach the Millennium Development Goals. Context includes
the relationship between availability and requirement for freshwater resources,
as well as the socio-economic circumstances of the country. Four examples will
illustrate this point.
Regions with a tropical monsoon climate (ample water but high variability in time)
and low levels of investment in water storage infrastructure.2 In these situations,
meeting the Millennium Development Goals may require:
A signicant investment in water storage capacity.
Diversication of water sources.
Development and implementation of early warning systems based on
climate prediction tools.
Development of contingency plans.
Chapter 11
149
Areas where the impact of climate change on water resources is anticipated to be

grave, leading to more frequent and severe oods, droughts, mudslides, typhoons,
and cyclones.3 Here, actions might include:
Greater investments in storage capacity.
Increased investment in technologies, capacity, and institutional structures to monitor and predict extreme weather events (early warning systems).
Improved national disaster preparedness and planning.
Zoning regulations (or improved enforcement of existing regulations)
that keep people from living in areas regularly destroyed by oods.
Long-term national water management plans that take into account
the affects of climate change and focus on achieving the Millennium
Development Goals.
Water-scarce regions, in which water is a limiting factor in the achievement of the
hunger Goal.4 Here, actions might include:
Identifying new incentive structures for water use and conservation to
inuence unsustainable consumption patterns.
Identifying unsustainable agricultural subsidies and trade barriers and
assessing the degree to which trade can help solve regional food deciency problems.
Closing the productivity gap between what can be and what is produced by exploiting the potential for water productivity gains in rainfed and irrigated areas through innovative agronomic, economic, and
social interventions.
Facilitating the diffusion and use of new technologies for increasing
water productivitywhether low-tech or high-techin irrigated and
rain-fed agriculture.
Closing nutrient loopsmaking sure that nutrients are returned to agricultural lands and improving soil fertility through the reuse of urban
domestic wastewater for periurban agriculture.
Regions in which current levels of economic and social activity impact on water
resources, leaving them inadequate to meet the health and environmental sustainability Millennium Development Goals or where future depleting water use will
further threaten aquatic ecosystems and the goods and services that they provide. In
these situations, actions might include:
Investment in infrastructure to reduce the environmental impact of
urban and industrial activity, which may include both water-specic
infrastructure (sewage treatment works) and broader investments (slum
upgrading, may dramatically reduce diffuse pollution).
Identifying minimum ecological service criteria for protection of aquatic
ecosystems against water depletion.
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Part 2
National-level monitoring of aquatic ecosystem health, public health,

water quality and quantity, and biodiversity.
Establishing national policies, strategies, and institutions and developing national environmental action plans.
Using the tools of environmental economics for reecting the true value
of ecosystem services and the real costs of pollution.
Chapter 12
Monitoring and support systems
This chapter explores how the global community can help monitor the nature,
quality, quantity, and current and projected uses of water resources for all the
Millennium Development Goals, and how it can better support national governments in their efforts to address a range of water and sanitation questions.
The following discussion and set of recommendations relates both to United
Nations organizations and to their international partners.
Monitoring water resources
Monitoring is a critical component of planning and action. Monitoring change

in situations over time is necessary to gauge the effectiveness of interventions
and measure the impact of policy reforms and investment at the national and
subnational levels. Monitoring is also critical to compare needs and prioritize
action among countries at the international level, which implies a need for
standardized approaches, data, and methods of gathering information. And at
all levels, civil societys most powerful advocacy tool is accurate information,
the end product of reliable monitoring efforts.
The challenges related to tracking progress in the development and management of water resources for all the Millennium Development Goals are
very different from those involved in tracking progress in expanding access to
domestic water supply and sanitation services as called for in target 10. Target
10 is in itself a measurable goal, whereas water resources management is not
an end in itself, but rather an input to efforts to increase food production,
reduce poverty and disease, and protect ecosystems. The international community has a fairly well-developed conceptual framework and institutional
mechanism for monitoring target 10, but the frameworks and institutions for
monitoring water resources management and development in relation to the
Millennium Development Goals are still in their infancy. As a result, mea-
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Part 2
Three types of
suring success in this area presents a host of issues that have not yet been
resolved.
intermediate
targets could
be monitored:
process
measures,
output
measures,
and impact
measures
Conceptual framework
Although the international community does not yet have a conceptual framework for monitoring water resources for all the Millennium Development
Goals, we present below what we believe to be four essential foundations on
which such a conceptual framework might be built:
A framework for sorting out the ways in which the development, management, and use of water resources will affect the Millennium Development
Goals. Table 10.1 captures the specic parameters that need to be monitored to ensure that the development, management, and use of water is
having the best possible impact on the achievement of the Millennium
Development Goals. Meeting the poverty target (target 1), for instance,
will require not only attaining equity in access to safe drinking water,
but also reducing poor peoples vulnerability to such water-related diseases and disasters as oods and droughts.
A set of intermediate targets that relate the development, management, and
use of water resources to each of the relevant Millennium Development targets. Following the concept of nested systems frameworks (Small and
Svendsen 1992), the relationship between water and any one of the Millennium Development Goals can be described as a set of nested systems,
each with its own particular set of intermediate objectives. The primary
link between these systems is that the outputs from one system become
part of the inputs into the next system. In this context, three types
of intermediate targets could be monitored: process measures, which
refer to the processes internal to any given system; output measures,
which describe the quality and quantity of outputs at a point where
they become inputs to the next higher system; and impact measures,
which refer to the impact of these outputs on the Millennium Development Goals as a whole. This approach requires monitoring not only
the inputs and outputs of any subsystem, but also the efciency with
which inputs to any subsystem are turned into outputs. In relation to
the hunger target, for example, it is important to measure not only the
water consumed in irrigated agriculture and the resultant food output,
but also the relationship between the twothe crop per drop ratio.
For each intermediate target, an analytical system to dene and measure the
target. As with target 10, this effort will require, for each intermediate
target, terminology for dening precisely what we mean by the contribution of water resources management and development for that target,
the operational meaning of the agreed terminologies, and survey instruments and indicators for assessing progress in water resources management and development toward the target. In the case of the hunger target,
Chapter 12
Intermediate
targets
for water
resources
will need to
give attention
to both
development
and
management
153
for example, an intermediate target might be the proportion of land area

that is effectively irrigated in relation to the proportion of land area that
would need to be irrigated if the hunger target is to be met. For both the
poverty and the hunger targets, one parameter to monitor might be the
degree to which the unequal distribution of water in time and space can
be controlled, for example, by measuring the proportion of storage infrastructure (both surface and subsurface) and early warning systems that
are effectively in place in relation to the infrastructure and management
systems that would be needed to effectively control oods and droughts.
A system for monitoring the extent to which each countrys vision of integrated water resources management is translated into tailored solutions as
a base for achieving the Millennium Development Goals as a whole. As
noted earlier, there is increasing acceptance that the management of
water resources must be undertaken with an integrated approach. Management decisions to alleviate poverty, to allow economic development,
to ensure food security and the health of human populations, as well
as preserve vital ecosystems, must be based on our best possible understanding of all relevant systems. From this point of view, the implementation of one of the task forces fundamental propositionsthat
countries should elaborate coherent water resources development and
management plans that will suppport the achievement of the Millennium Development Goals as a whole (see chapter 13)also needs to
be carefully monitored. In the short term, this implies monitoring the
implementation of the target set in Johannesburg, which requires countries to have formulated integrated water resources management strategies by 2005.
Clearly, these four essential foundations only begin to scratch the surface
of the needed conceptual framework for monitoring water for all the Millennium Development Goals. In further developing this framework, a wide range
of issues will need to be taken into account. Perhaps the most important is that,
since the relationship between water and the Millennium Development Goals
is enormously site specic, intermediate targets and milestones will need to be
set and monitored at national and subnational levels. In addition, baseline dates
will need to be set for all targets (1990 is recommended in all cases, unless special circumstances dictate otherwise). Finally, as with target 10, intermediate
targets for water resources will need to give attention to both development and
management issues, recognizing the key role of investment in infrastructure
and the vast deciencies in infrastructure endowments in the poorest countries
most at risk of failing to achieve the Millennium Development Goals.
Institutional mechanisms
Within the overall reporting process referred to earlier, there is currently no
global system in place to produce a systematic, continuing, integrated, and
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Part 2
The World
Water
Assessment
Programme
focuses on
assessing the
situation of
freshwater
throughout
the world
comprehensive global picture of freshwater and its management in relation to

the Millennium Development Goals. Designed to help close this gap is the
World Water Assessment Programme (WWAP), which focuses on assessing
the situation of freshwater throughout the world (WWAP website). Its primary
output is the periodic World Water Development Report (UN/WWAP 2003).
The current report, which came out in 2003, will be updated every three years;
the next volumes are slated for 2006, 2009, 2012, and 2015. The program
focuses on terrestrial freshwater, but links with the marine near-shore environments and coastal zone regions as principal sinks for land-based sources of
pollution and sedimentation and as areas where the threat of ooding and the
potential impact of sea level rise on freshwater resources is particularly acute.
The WWAP is undertaken by UN agencies working in concert under the
auspices of UN-Water. The program is hosted by UNESCO and serves as an
umbrella for coordination of existing UN initiatives within the freshwater
assessment sphere. In this regard it links strongly with the data and information systems of the UN agencies.1 Currently, the compilation and development of indicators are being undertaken in all key areas of water resources and
reected in the World Water Development Report. Organized in terms of the
Millennium Development Goals, these areas include:
Goal 1: eradicate extreme poverty and hunger
Food security. Food security, particularly of the poor and vulnerable,
depends upon the more efcient mobilization and use of water and the
more equitable allocation of water for food production.
Water and industry. Industry needs and private-sector responsibility to
respect water quality and take account of the needs of competing sectors
has a signicant impact on water quality and quantity.
Water and energy. Water is vital for all forms of energy production, and
there is a need to ensure that energy requirements are met in a sustainable manner.
Risk management. There is tremendous need in developing countries
to provide security from oods, droughts, pollution, and other waterrelated hazards, especially in light of climate change.
Goals 4, 5, and 6: reduce child mortality; improve maternal health; and
combat HIV/AIDS, malaria, and other diseases
Meeting basic needs. Because of its importance in the promotion and protection of human health, access to safe and sufcient water supply and
sanitation is a basic human right and essential to health and well-being.
Goal 7: ensure environmental sustainability
Protecting ecosystems. Safeguarding the integrity of ecosystems requires
sustainable water resources management.
Chapter 12
The World
Water
Development
Report
appears
to be the
most viable
mechanism
for
periodically
reporting on
progress
155
Water and cities. Urban areas are increasingly the focus of human settlements and economic activities, and they present distinctive challenges
to water managers.
Integrated approaches to achieve all goals
The nature of the resource. The availability of water (quantity and quality) from all sources and its variation through time affect all aspects of
development.
Valuing water. Managing water in a way that reects its economic,
social, environmental, and cultural values in all its uses and moving
toward pricing water services to reect the cost of their provision, taking
account of the need for equity and the basic needs of the poor and the
vulnerable, are important components of sound water management.
Governing water wisely. Good water governance requires the involvement of the public and the interests of all stakeholders in the management of water resources.
Ensuring the knowledge base. Good water policies and management
depend upon the quality of knowledge available to decisionmakers.
Sharing water resources. Promoting peaceful cooperation and developing
synergies among different users of water at all levels within and between
states through sustainable river basin management or other appropriate
approaches is critical.
Clearly, much needs to be done to help the World Water Development Report
system become an effective process to monitor water resources for the Millennium Development Goals. In addition to conceptual problems, enormous
measurement challenges remain to be tackled. Just to take one example, data
and information collection is not done in a systematic and consistent fashion
at any level, and thus it is difcult to compare data over time or between countries. In addition, there are problems of denition. Despite these challenges,
the World Water Development Report appears to be the most viable mechanism
currently available for periodically reporting on progress made in the area of
water resources development and management toward achieving the Millennium Development Goals as a whole.
In addition to monitoring the larger question of water resources for all the
Millennium Development Goals, the international community should support
and track progress on the development of plans and strategies for integrated
water resources management and efciency by 2005, as called for in the Johannesburg Plan of Implementation. The information gathered through these
monitoring processes can be used by the international community during the
second Water Decade, Water for Life, which runs from 2005 to 2015, to
mobilize international awareness and political commitment to water resources
planning, development, management, and use to meet the Millennium Development Goals (UNESCO website).
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UN
organizations
need to play
a strong
supporting
role
Global institutional support structures
Direct action to manage and develop water resources to meet the Millennium
Development Goals should take place as close as possible to where the problems and opportunities lieprincipally at national and subnational levels.
Nevertheless, UN organizations with their international partners (including
international water and sanitation networks and partnerships) need to play
a strong supporting role. In particular, they need to assist countries to meet
the water supply and sanitation target and to manage water resources through
technical support and capacity building, objective analysis and knowledge
sharing, global monitoring, and advocacy functions. The need for these types
of support was one of the key lessons of the International Drinking Water Supply and Sanitation Decade (see box 1.2). These functions need to be effectively
aligned toward the achievement of the Millennium Development Goals, and
they need to be accompanied by international leadership and strategic guidance through a clear mechanism that builds on each organizations strengths
and comparative advantages and reduces duplication.
The way in which UN organizations and their partners (including international water and sanitation networks and partnerships) presently support
national water and sanitation efforts could be substantially improved. The current system has two characteristics that both contribute to its weaknesses and
set it apart from the way in which the international community addresses other
Millennium Development Goal issues, such as hunger or health.
First, some 24 UN system organizations and a number of international water
and sanitation networks and partnerships are involved in water resources and
sanitation. There is no single lead agency (as, say, FAO is for agriculture and
WHO is for health). With so many actors involved in water and sanitation,
ensuring coordinated and effective action that is aligned with the Millennium
Development Goals is a challenge; indeed, organizations sometimes compete
with one another, and turf battles occur. The United Nations System Chief
Executive Board for Coordination endorsed UN-Water in November 2003 as the
new ofcial United Nations systemwide interagency mechanism for follow-up of
the water-related decisions reached at the World Summit on Sustainable Development 2002 and the Millennium Development Goals (box 12.1). The new
terms of reference of UN-Water respond to the need to increase coherence and
coordination at inter-agency and country levels and also to the needs described
earlier concerning coherent and coordinated leadership (UN DESA website).
Nevertheless, the task force is concerned that UN-Water does not have adequate
budget or staff to execute these functions at the scale required, especially in light
of the policy prominence of water and sanitation in the forthcoming decade.
Second, in the past 15 years, most UN system organizations have experienced pressure to respond to emerging issues. Declining contributions to many
organizations coupled with these increased demands have tended to reduce core
funds and increase reliance on nancing tied to pre-dened areas of work. The
Chapter 12
Box 12.1
The evolution
of interagency
coordination in
water resources
and sanitation
157
Cooperation and coordination among UN agencies in the area of water resources started
with the Intersecretariat Group for Water Resources, which was established in 1977 following the UN Water Conference at Mar del Plata, Argentina. The intersecretariat dened
areas where interagency collaboration would be important, such as in the implementation
of the International Drinking Water Supply and Sanitation Decade, which extended from
1981 to 1990. After the Earth Summit in 1992, the intersecretariat was integrated into
the former Administrative Committee on Coordination as the ACC Subcommittee on Water
Resources. In 2000 the subcommittee started a long-term project called the World Water
Assessment Program, the main product of which is the World Water Development Report
(UN 2003). Following the recent restructuring of the ACC, the members of the UN system
entities dealing with water formed UN-Water, the United Nations Inter-Agency Committee on Water Resources. In late 2003, the United Nations System Chief Executive Board
for Coordination (CEB) formally established UN-Water as the interagency mechanism for
follow-up of the water-related decisions coming out of the 2002 World Summit on Sustainable Development and the Millennium Development Goals concerning freshwater.
overall effects of these trends vary among organizations, but have included a
reduced emphasis on water and sanitation, wide gaps between mandated responsibilities and delivery capacity, and a resulting inability to provide intellectual
and practical leadership. In parallel, several international networks and partnerships have emerged and are active in technical analysis, knowledge sharing, and
advocacy. These entities include the Water Supply and Sanitation Collaborative
Council (WSSCC website), the Global Water Partnership (GWP website), and
the World Water Council (WWC website), as well as nongovernmental organizations such as WaterAid. This diversity of actors contributes much to the
strength of international water and sanitation support and advocacy, but also
creates new challenges to coordination to ensure effective coherent action.
Recommendations for the international community
To reach the Millennium Development Goals, the problems identied above

need to be addressed forthrightly and urgently.
United Nations system organizations and their member states must
ensure that the UN actors engaged in technical support and capacity
building, objective analysis and knowledge sharing, global monitoring,
and advocacy have, both individually and collectively, the organizational capacity, mandate, stafng, and resources needed to carry out
these functions.
At the country level, UN Country Teams must strengthen their efforts
to provide technical and capacity-building support to governments,
including in the preparation of national strategies for water supply
and sanitation based on the Millennium Development Goals, as well
as strategies for integrated water resources management and water efciency. Likewise, development banks and bilateral donor agencies must
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The provision
of leadership
and strategic
guidance
to the
international
community
is essential
effectively coordinate their actions at the country level, including harmonization of procedures and joint programs.
The WHO/UNICEF Joint Monitoring Programme must be strengthened as the key global mechanism for monitoring access to water supply
and sanitation and provided with greater funding. WHO and UNICEF should ensure that arrangements increasingly enable contribution
to and participation in the JMP. Bilateral agencies should both provide more funding and refrain from setting up parallel structures. UNWater should be mandated to periodically report, through the World
Water Development Report, on progress in water resources development
and management for the Millennium Development Goals, including
progress on the development of strategies for integrated water resources
management and efciency by 2005. UN-Water and World Water
Development Report must be strengthened and provided with greater
funding to fulll these roles successfully.
At the global level, provision of leadership and strategic guidance to the
international community is essential. UN organizations and key operational
actors and others involved in water and sanitation must be involved in this
effort through a clear mechanism that should build on each organizations
strengths and comparative advantages and reduce duplication. The recently
dened mandate and widened participation of UN-Water correspond closely
to this need, but this mechanism presently has neither the necessary funds nor
staff. Several options exist:
A multiagency entity (such as the Global Fund to Fight HIV/AIDS,
Tuberculosis and Malaria or UNAIDS) could be created to act as the
main advocate for global action on water and sanitation and to lead,
strengthen, and support national scaling-up efforts. Such a mechanism
would need to include the key operational actors in water and sanitation, build on the various organizations strengths and comparative
advantages, and have a clear joint strategy, designation of roles and
responsibilities, a program of action, and accountability for results. UN
Water, which has recently been reconstituted to include broader representation from non-UN bodies, could be transformed into a body with
this responsibility; at present the entity has neither the funding nor staff
to take on this role, but with a concerted capacity-building effort over
the next year, it might be possible for it to assume that responsibility
within a reasonable timeframe.
A second option would be to establish a truly operational group and
program on water and sanitation with the key operational bodies in and
outside the UN system. The program would need to be well funded and
staffed, with a clear mandate to act on achieving the targets and possibly a sunset clause in 2025.
Chapter 12
The global
networks and
the funding
agencies
supporting
them must
strengthen
and
rationalize
their efforts
159
A third option would be to assign UN system task managers for the

various aspects of water resources and water supply and sanitation.
WHO and UNICEF, for example, could take the lead in sanitation;
UNESCO or UNEP in the management of freshwater resources.
In addition, the recently established Secretary Generals Advisory Board
on Water and Sanitation must focus on providing high-level policy commentary on progress toward the water and sanitation target, advising on strategic
direction, identifying critical obstacles to progress, and making recommendations for overcoming them. It should independently and boldly comment on
developing country, donor country, and UN system practices, and produce
a periodic, brief, focused, high-prole report that would eschew advocacy in
favor of pointed recommendations aimed at improving progress within the sector and at advancing the sectors position in the development arena.
Finally, the global networks engaged in water and sanitation and the funding agencies supporting them must collectively strengthen and rationalize
their efforts to provide technical support, capacity-building, objective analysis, knowledge-sharing, and advocacy functions, and align those functions
towards the achievement of the Millennium Development Goals, while at the
same time taking steps to ensure they are accountable to the communities of
the developing world.
Achieving the Millennium

Development Goals
Chapter 13
How to make the Goals a reality
Expanding water and sanitation coverage is not rocket science. It requires neither colossal sums of money nor breakthrough scientic discoveries or dramatic
technological advances. Although reaching the water and sanitation target will
by no means be easy, particularly in the very poorest parts of the world, and
worldwide the sanitation challenge is indeed daunting, achieving target 10 is
possible.
The critical question is, how? This chapter focuses on the answer. Based
on the analyses presented in the previous chapters, what do we, as a task force,
think it will take to meet the water and sanitation target and to optimize water
resources management for the entire set of Millennium Development Goals?
More specically, what are the key actions that we have identied as essential
to meeting the Millennium Development Goals?
A call to action
We would like to set the stage by rst identifying ve critical guiding principles
without which the Millennium Development Goals simply cannot be achieved.
The task force is unanimous in its belief that the water and sanitation target (target 10) will not be reached unless:
There is a deliberate commitment by donors both to increase and refocus
their development assistance and to target sufcient aid to the poorest lowincome countries.
There is a deliberate commitment by governments of middle-income countries that do not depend on aid to reallocate their resources so that they target
funding to their unserved poor.
There are deliberate activities to create support and ownership for water
supply and sanitation initiatives among both women and men in poor
communities.
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Local,
subnational,
and national
governments
have the
primary
responsibility
for expanding
access
There is a deliberate recognition that basic sanitation in particular requires

an approach that centers on community mobilization and actions that support and encourage that mobilization.
Furthermore, our group is convinced that the Millennium Development
Goals as a whole will not be met unless:
There is deliberate planning and investment in sound water resources management and infrastructure.
Without these ve preconditions, the poorest countries will miss target 10;
the poorest people in on-target middle-income countries will be left behind;
many of the gains that are made will not be sustained; the sanitation crisis
will continue unabated; and, in many countries, water scarcity, variability, and
contamination will hamstring progress toward all the goals.
Our starting points are thus clear: poor people and poor countries must get
priority, and resources and policies must be focused on spurring and supporting
community-led action. The key to reaching the targets will be to mobilize and
support people themselves, country by country, particularly in slums, rural
areas, and other marginalized communities where access to services is lowest.
Consistent with this focus on ground-level action, we believe that local,
subnational, and national governments have the primary responsibility for
expanding access to water supply and sanitation services. National governments
must stand by their commitments to the Millennium Development Goals by
making them priority national development goals, preparing strategies and
action plans for their achievement, opening doors for community action, and
mobilizing public awareness and support, especially for sanitation and hygiene.
Though governments need not engage directly in service delivery, they do need
to set standards for service providers (including public utilities and the private
sector), and they must intervene, if necessary, to make things happen.
To make the Millennium Development Goals a reality for everyone, countries must focus their efforts and resources where needs and challenges are
greatest, particularly among concentrations of very poor people in urban slum
areas, periurban areas, and rural areas. They must ensure that the nancial
burden of serving the poor is not borne by the poor alone. For upper low- and
middle-income countries, this commitment principally means that existing
resources must be used more effectively. To make subsidies for the poorest
possible, governments must end subsidies for the nonpoor. This reallocation of
resources will require signicant political will and commitment, since ensuring basic services for all rather than subsidizing luxury service for some will
challenge powerful interests and create a new set of winners and losers.
That said, there is clearly a critical supporting role for international agencies,
international nongovernmental organizations (NGOs), and, most importantly,
donor countries, which have also committed to the Millennium Development
Goals. Most of the countries with the lowest levels of human development and
that have made the least progress over the past ten years are stuck in poverty
Chapter 13
Ofcial
development
assistance
should be
targeted
within
countries
to programs
that benet
the poorest
165
traps, bypassed by economic development because of structural impediments

like geography, climate, the burden of disease, rapid population growth, heavy
debt burdens, dependence upon primary commodity exports, and the inequities of the global current trade regime. For these countries, all the governance
reforms, enabling policy environments, and social mobilization efforts in the
world will not address the fact that domestic resources are simply inadequate
to support a meaningful expansion of services. Without more ofcial development assistance, these countries simply cannot meet the water and sanitation
target; they do not have and cannot generate sufcient resources from any
other source. To meet the Goals, donor countries must fulll their side of the
Monterrey compact to provide more aid, as well as increase the efciency of aid
through better coordination.
At present, there is often an inherent tension in the process: Should countries outline in a serious way what it would truly take to meet the Millennium Development Goals or should they outline what they believe they can
achieve within likely levels of development assistance? For the poorest countries
most off-track for meeting the Millennium Development Goals, it is crucial
to make transparently clear the gap between what they could achieve with
likely levels of development assistance and what they really need in order to
achieve their goalsand for the international community to step in with the
necessary funding. In the water sector, donors and developing countries alike
have become accustomed to identifying what can be done within the connes
of existing aid allocations and national budgetary limits. To meet the Goals, this
process must be turned on its head, with identication of needs and demands
coming rst and appropriate allocations being made second.
To ensure inclusion of and priority for the poor, the vulnerable, and the
remote in improved services, ofcial development assistance should be targeted
within countries to programs that benet the poorest. Subsidies should focus
on access rather than consumption and should help to attract rather than take
the place of community and private resources. Grant-based aid should never go
to projects that will primarily benet the middle- and upper-income groups.
For low- and middle-income countries, actors at the international level can play
a pivotal role as advocates, catalysts, mobilizers of international support, and
sources of additional resources. The framework for this support must be national
development planning and budgeting processes that focus on achieving the Millennium Development Goals. There is also a particular need for nancial instruments that protect countries from risks, such as adverse currency movements.
Ten critical actions
Meeting the water and sanitation target and optimizing water resources for the
Millennium Development Goals by 2015 will require a dramatic scaling-up of
effortsdramatic in terms of both the extent of action required and the speed
with which these actions must be undertaken. The nancial, governance, and
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Part 3
Scalingup service
delivery in
the poorest
countries
will require
unprecedented shortterm action
capacity constraints low-income countries face will make this a complicated

challenge. Scaling-up service delivery in the poorest countries will require
unprecedented short-term action, as well as a focus on building the management systems needed to implement large-scale programs over the medium
term and to sustain the gains made over the long term. It will also require
a departure from business as usual on the part of all key actors, and new
approaches that center on decentralization, transparency in budgetary allocations, and massive capacity-building efforts right down to the village level.
This dramatic scaling-up of efforts that meeting the ambitious Millennium
Development Goals and targets entails will require very signicant investments, both in infrastructure and in institutional strengthening and reform, as
well as at least ten complementary actions necessary to underpin them. These
ten actions can be crystallized as follows:
Action 1. Governments and other stakeholders must move the sanitation
crisis to the top of the agenda.
Water supply and sanitation, occasionally joined by hygiene, are words that
often appear together in speeches and pronouncements, and indeed this trio
belongs together as a cornerstone of public health, as well as social and economic well-being. Sanitation and hygiene, however, somehow disappear during the planning, policymaking, budgeting, and implementation phases, while
the lions share of effort and resources are allocated to water supply. This needs
to change: sanitation and hygiene promotion need to move front and center
rather than continuing as add-ons to water supply. They are key to development
with dignity.
Fundamentally, advocates and sector professionals must not be afraid to
tell the plain, ugly truth about what really happensnamely, open defecation. That 42 percent of the worlds people lack what virtually all readers of
this report take for granteda toiletis a travesty with devastating impacts
on peoples daily lives, health, and self-respect; we should not be afraid to say
so. Here, lessons from the successes in galvanizing global support for the HIV/
AIDS epidemic are important; only when policymakers, civil society groups,
and the woman and man on the street started speaking openly about how HIV
spreads (mainly sexual contact) and how to stop it (condoms, monogamy) did
rates of new infection start to decline.
In many cases, countries must approach the challenge of improving sanitation service with different strategies than those employed to expand access
to water supply. Expanding sanitation depends not just on building latrines,
but also on understanding what motivates people to act in certain ways, and
then nding ways to capitalize on those motivations. Mobilization, education,
communication, and social marketing, aimed at households, communities,
schools, and public authorities are key. The focus needs to be on decisions
and investments made at the household and community levels, rather than on
Chapter 13
Having a
leadership
role in
community
management
of water
supplies can
increase
womens
social capital
167
installation of hardware. More and different types of people need to be pulled

into this effort, including NGOs, womens groups, religious organizations,
schools, youth groups, small-scale service providers, and local entrepreneurs;
indeed, many traditional sanitation service providers will need to create space
for more actors to enter, inuence, and support the market.
Innovation, pragmatism, and, above all, community solidarity and mobilization must be brought to bear to nd local solutions that respond to local
needs in an affordable and effective manner. Design of sanitation facilities
must respond to user preferences, beliefs, and practices; demand for different
technical options; motivations for change; and capacity to maintain facilities
in the long term. As in all sound marketing practice, sanitation promotion
should take into account the distinct needs and preferences of different consumer groups, such as women and children.
Given the enormous ground to be covered to meet the sanitation target, the
hallmarks of sanitation strategies should be maximum scalability, minimum
transactions costs, full nancial accountability, and closed revenue cycles, along
with technical feasibility and operational and environmental sustainability.
Action 2. Countries must ensure that policies and institutions for water
supply and sanitation service delivery, as well as for water resources
management and development, respond equally to the different roles,
needs, and priorities of women and men.
Gender differences and inequalities are fundamental to all efforts aimed at
improving water supply, sanitation, and water resources management. Because
they shoulder the lions share of domestic responsibilities, women and girls suffer disproportionately when water supply and sanitation services are decient.
Across virtually all cultures, women have a greater need than men for facilities
that are safe, private, and near their homes. In water resources management
and development, women and men often have different priorities; women, for
instance, often prioritize water for domestic use and household gardens, while
men want water for irrigating cash crops. Womens relative access to and control over water (and other key resources linked to water, such as land, credit,
and extension services), as well as gender biases within public institutions,
greatly affect the degree to which women can take part in and benet from
water management and development schemes.
Addressing this reality is critical for the effectiveness and sustainability of
water and sanitation interventions. In addition, community action and social
mobilization around the provision of basic social services like water have been
shown to be a valuable entry point for promoting womens empowerment. Having a leadership role in community management of water supplies, for instance,
can increase womens social capital as well as their bargaining power within the
household. Priority should be given to policies that capitalize on the potential
synergy between the water and sanitation target and the gender equality Goal.
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This focus
on service
delivery
should also
extend to
monitoring
systems
Action 3. Governments and donor agencies must simultaneously pursue

investment and reforms.
Meeting the water and sanitation target by 2015 will require a dramatic scaling
up of effortsdramatic in terms of both the extent of action required and the
speed with which these actions must be undertaken. Waiting for reforms to be
implemented before making the necessary investments will make it impossible to
meet the 2015 deadline. Over the past decade, donors have often made funding
for infrastructure and service delivery contingent upon capacity building and
institutional reform. However, in a number of cases, the acquired skills atrophied
before the investments materialized, or the reforms were merely cosmetic. In
other cases, expected ofcial development assistance or funding from private-sector investment in service delivery following institutional reform never appeared.
Allowing reforms and investments to take place simultaneously, which some call
learning by doing, will help address the tension between the desire to have reforms in place before investments and meet the Millennium Development Goals
by the deadline of 2015. It will also ensure that reforms are grounded in reality.
This parallel approach could be made contingent upon a credible program of
investments and a commitment (at the highest level) to simultaneous reforms.
Action 4. Efforts to reach the water and sanitation target must focus on
sustainable service delivery, rather than construction of facilities alone.
The Millennium Development Goals necessarily focus on measurable targets,
such as the proportion of people without access to water supply and sanitation.
It is important to remember, however, that water supply and sanitation are
services, not simply facilities. The former is a processrequiring the sustained
involvement of government, service providers, and householdswhile the latter is a product that can be delivered in a one-off project. Adopting a service
orientation requires attention to nancial ows and institutional arrangements
for operations and maintenance, as well as incentives for providing safe, reliable services to all customers (including the poor) on a continuing basis. This
approach is being contemplated in Brazil, where government has proposed
subsidizing service for the poor contingent not on the provision of physical
infrastructure, but rather on the supply of reliable service.
This focus on service delivery should also extend to monitoring systems.
Monitoring and assessment systems for access to water supply and sanitation
services need to be active and adequately resourced from the sub-national to
the international level. These systems need to employ valid and reliable measures of access to water supply and sanitation services. More specically:
Access to services, rather than to infrastructure, should be at the center of monitoring efforts. The parameters that matter most to users
including the convenience, reliability, sustainability, and adequacy of
water supply and sanitation servicesshould be measured over time, as
should equity of access by women and the poor.
Chapter 13
Water supply
and sanitation
service
delivery
should be
managed at
the lowest
appropriate
level
169
Monitoring systems should employ a sample survey approach.

Collected data should be shared in user-friendly formats with NGOs,
civic groups, and the public at large, as well as with national and international institutions.
Action 5. Governments and donor agencies must empower local authorities
and communities with the authority, resources, and professional capacity
required to manage water supply and sanitation service delivery.
Water supply and sanitation service delivery should be managed at the lowest
appropriate level; however, this devolution of responsibility must be accompanied by corresponding devolution of nancial resources and authority, as well
as the provision of technical and managerial support to build local capacity.
Decentralization of authority and responsibility to local institutions that lack
the requisite technical, managerial, or nancial capacity and authority for planning and service delivery can hinder, rather than accelerate, the expansion of sustainable services. Partnerships with local businesses, womens organizations, and
other NGOs can be used to help build capacity in local governments and move
the service-expansion agenda forward. Civic organizations can help promote
accountability through facilitation of information dissemination and citizens
exercise of voice and demand for services. Also important is the careful balance
of authority between local institutions and the centerfor example, with respect
to setting standards and subsidy policiesso that the interests of low-income
households are protected. Central governments should take explicit measures to
ensure that decentralization of service provision is not captured by local elites; it
should rather create incentives for local governments to serve the poor.
There are strong links between local government reform and reforms in
water supply and sanitation sectors. The provision of water supply and sanitation services can, in some instances, be pivotal for strengthening local governments. It can also provide an effective entry point for womens participation
(action 2) in local political processes, particularly when the equal representation of women in water management is a design feature of programs and
policies. An emphasis on service provision (action 4) implies a greater focus on
ongoing management, which depends upon effective local institutions.
Action 6. Governments and utilities must ensure that users who can pay
do pay in order to fund the maintenance and expansion of servicesbut
they must also ensure that the needs of poor households are met.
Only service providers that have adequate funds can operate and maintain
present systems properly and establish the creditworthiness needed to support
service expansion. Closing the revenue gap depends both on reducing costs
and increasing revenues. Improving revenue collection can often be achieved
simply by charging for what is delivered and collecting bills in a timely manner.
Households and communities are capable of making responsible decisions
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Part 3
The nancial
burden of
serving the
poor cannot
be borne
by the poor
alone
about investments in sustainable water supply and sanitation, and will pay for
them if service providers can be held responsible and accountable for the quality of the service they provide. In fact, willingness to charge by governments
and service providers is often the limiting factor for adequate revenue generation and resource mobilization. Governments must set an example in their
communities by paying their own water bills promptly and in full.
At the same time, governments must recognize that the nancial burden
of serving the poor cannot be borne by the poor alone. Some poor families
and communities simply cannot pay for water supply and sanitation services;
carefully targeted subsides for this group are essential. Where the needs of the
poor are not being met because available public resources are being captured by
the rich and powerful, appropriate reforms must be implemented. Communitybased nancing or micronancing may be a starting point, building a domestic
nancing system in the process. Governments can also develop nancial
models for support to nongovernmental and community-based organizations,
which can often deliver services at lower costs.
In many areas without access to improved services, however, the nancial
resources for meeting the Millennium Development Goals must come from
outside the communities concerned. Part of the additional funding must come
from those already served, using appropriate cross-subsidies; part may come
from national income redistribution mechanisms; and part from international
donors. In general, subsidizing access (connections in network systems, for
example) has proved to be a more transparent way of targeting the poor as
compared to subsidizing consumption (for example, monthly bills). In addition,
even in the poorest communities beneciaries can typically contribute to the
costs of improved service through various forms of in-kind contributions. Such
contributions engender a sense of ownership necessary for sustainability.
It is also critical to recognize that nancial sustainability for water supply
and sanitation systems requires discipline within national-level budgeting
processes. No system should be built unless it is known how it will be
nancednot just the initial capital investment, but also the costs of operation
and maintenance. Budgeting processes in general also need to become more
transparent. Reduction of corruption at all levels, including in the donor
organizations and international agencies, is key.
Action 7. Within the context of national poverty reduction strategies
based on the Millennium Development Goals, countries must elaborate
coherent water resources development and management plans that will
support the achievement of the Goals.
Acting on this recommendation clearly requires that there is a coherent poverty reduction strategy in place from which a water resources development
and management plan can be derived. Ideally, an integrated water resources
management strategy based on the Goals will entail:
Chapter 13
Innovation in
institutional
and nancial
mechanisms
could
accelerate
progress
171
An assessment of the nature of a countrys freshwater supply from all

sources (both surface and groundwater), taking into account such key
factors as the infrastructure already in place for water abstraction, the
water available from shared sources, variability in time and space, and
water quality.
An assessment of the nature of the demand for water resources to meet
poverty, hunger, health, and environmental sustainability Goals.
A coordinated process to reconcile the supply and demand for water
resources, one which conforms broadly to the recommendations from
the Johannesburg Summit regarding the preparation of integrated water
resources management and water efciency plans by 2005.
A coherent strategy for the implementation of such plans.
Action 8. Governments and their civil society and private sector partners
must support a wide range of water and sanitation technologies and
service levels that are technically, socially, environmentally, and
nancially appropriate.
Supporting a broad range of technological choices allows communities to
install the water supply and sanitation infrastructure that they want, are willing to pay for, and can maintain in the long term; it can also lower per capita
costs, thus permitting limited resources to bring service to more households.
Hand pumps, improved wells, rainwater harvesting, locally designed latrines,
installations using volunteer labor, community maintenance, and the promotion of small-scale independent service providers are examples of lower-tech
approaches that may be particularly relevant and cost-effective for many rural
and periurban areas. In some urban settlements, small, locally operated water
supply and sanitation systems may be less expensive to construct and maintain
than large, centralized systems.
Encouraging the development and use of a range of technologies and services levels helps to resolve the tension between the need for a swift scaling-up
of services to meet the 2015 target and the aim of sustaining the gains made
over the long term. One-size-ts-all approaches necessarily mean that some
households and communities end up getting the wrong services, namely,
those that are not technically feasible, socioculturally appropriate, or affordable for users, or that are simply not the types of services that users want. A
failure to respond to user preferences and circumstances all but guarantees an
eventual failure of the services themselves.
Action 9. Institutional, nancial, and technological innovation must be
promoted in strategic areas.
Innovation in institutional and nancial mechanisms, as well as technological
advances in key areas, could accelerate progress toward the water supply target,
the sanitation target, and the Millennium Development Goals as a whole.
172
Part 3
Innovation
in nancing
systems,
policies,
institutions,
and
technologies
is also
needed to
accelerate
progress
To meet the water supply and sanitation targets, innovation is particularly

needed in the nancial, policy, and institutional arenassuch as service delivery
systems that help service providers to ensure effective relationships with households and communities, to work with communities, households, local civil society, and private-sector partners, and to build capacity to innovate and adapt solutions. While most experts agree that a full complement of technologies is now
available for safe, reliable water supply in almost any setting, progress toward the
sanitation target is still constrained by the lack of technologies that are reliable
and affordable enough to implement on a wide scale without having negative
impacts on the environmental sustainability target. Technical advances in such
areas as effective, affordable, and simple-to-operate sewage treatment plants that
can be located close to residential areas; drainage and solid waste disposal; and
urban wastewater treatment and management in large urban agglomerations
should therefore be promoted and accelerated.
Innovation in nancing systems, policies, institutions, and technologies is
also needed to accelerate progress toward the Millennium Development Goals
as a whole. Win-win technical and institutional systems that advance more
than one Goal simultaneously, rather than achieve one goal at the expense of
another, are particularly needed. Examples include mechanisms to improve
crop per drop and thus both spur progress toward the hunger Goal and reduce
the demand for water; and programs for the reuse of waste water in agriculture,
which could contribute to both the sanitation and hunger targets.
Action 10. The United Nations system organizations and their member
states must ensure that the UN system and its international partners
provide strong and effective support for the achievement of the water
supply and sanitation target and for water resources management and
development.
UN organizations, together with their international partners (including international water and sanitation networks and partnerships), must strengthen
both their ability to assist and the level of their assistance to countries to meet
target 10 and to optimize water resources management and development. This
will contribute to the corresponding goal and targets directly and also to all
other Millennium Development Goals. Doing so will require that nancing,
technical support, capacity building, objective analysis, knowledge-sharing,
global monitoring and evaluation, and advocacy functions are effectively
aligned toward the achievement of the Millennium Development Goals.
United Nations system organizations involved in water and sanitation and
their Member States must therefore ensure that the UN system organizations
engaged in such functions have, both individually and collectively, the organizational capacity, mandate, stafng, and resources needed to carry out these
functions, and to provide leadership and strategic guidance to the international
community in these areas.
Chapter 13
UN
organizations
must
strengthen
their ability to
assist and the
level of their
assistance
173
The United Nations system organizations and their member states involved
in water supply and sanitation and in water resources development and management should take the following actions:
At the country level, the UN Country Teams should strengthen their efforts
to provide technical and capacity-building support to governments, including in the preparation of national MDG-based strategies for water supply
and sanitation and for integrated water resources management and water
efciency. UN organizations, development banks, and bilateral donor
agencies must also effectively coordinate their actions at the country level,
including harmonization of procedures and joint programs.
At the global level, provision of leadership and strategic guidance to the
international community is essential. UN system organizations and key
operational actors and others involved in water and sanitation must be
involved in this through a clear mechanism, which should build on each
organizations strengths and comparative advantages and reduce duplication. UN-Waterwith its recently dened mandate and widened participationshould be developed to this end. The WHO/UNICEF Joint
Monitoring Programme should be strengthened as the key global mechanism for monitoring access to water supply and sanitation and provided
with greater funding. WHO and UNICEF should ensure that arrangements increasingly enable contribution to and participation in the JMP.
Bilateral agencies should both provide more funding and refrain from setting up parallel structures. UN-Water should be mandated to periodically
report, through the World Water Development Report (WWDR), hosted
by UNESCO, on progress in water resources development and management for the Millennium Development Goals, including progress on the
development of strategies for integrated water resources management and
efciency by 2005. UN-Water and WWDR must be strengthened and
provided with greater funding to fulll these roles successfully.
The recently established Secretary-Generals Advisory Board on Water and
Sanitation should focus on providing high-level policy commentary on progress toward the water and sanitation target, advising on strategic direction,
identifying critical obstacles to progress, and making recommendations for
overcoming them. It should independently and boldly comment on developing country, donor country, and UN system practices; and produce a periodic, brief, focused, high-prole report that would eschew advocacy in favor of
pointed recommendations aimed at improving progress within the sector and
at advancing the sectors position in the development arena.
The global networks engaged in water and sanitation with the funding agencies supporting must collectively strengthen and rationalize their efforts to provide technical support, capacity-building, objective analysis, knowledge-sharing,
and advocacy functions, and align those functions towards the achievement of
the Millennium Development Goals, while at the same time, taking steps to
ensure they are accountable to the communities of the developing world.
Chapter 14
An operational plan
The 5 guiding principles and 10 actions presented in chapter 13 represent, in

broad strokes, the vital conditions needed both to achieve the Millennium
Development Goals for water supply and sanitation and to ensure that sound
water resources development and management underpins the broader effort to
reach all of the Millennium Development targets. These principles and actions
are further elaborated in this chapter within an operational plan that species the
steps that each actornational and subnational governments, donors, civic and
community organizations, and research institutionsmust undertake in support of the goals. Although the operational plan focuses only on actions by actors
in the water sector, investments in other sectors, such as health and education,
are crucial to the achievement of the water and sanitation targets. As stressed in
previous chapters, progress in eradicating extreme poverty and hunger, achieving
universal primary education, promoting gender equality, empowering women,
and ensuring environmental sustainability will all help in advancing progress
toward the Millennium Development targets for water and sanitation.
Operational plans for national and subnational governments, donors, civic
and community organizations, and research institutions, respectively, are outlined
in tables 14.114.7. In each table, entries in the action plan have been categorized
into immediate priorities, short-term priorities, and medium-term priorities.
National and subnational governments. National governments have principal responsibility for initiating the planning procedures and policy
reforms, as well as for committing the nancial and human resources,
necessary to achieve the Millennium Development Goals. In addition,
efforts by other stakeholder groups are often contingent upon strong
initial action by national governments. The proposed operational plan
should therefore be spearheaded by the actions that have to be taken
by national governments, as outlined in table 14.1. Since some actions,
Chapter 14
There is still
time for the
world as a
whole to meet
target 10
but only just
An operational plan
175
such as setting of standards for water and sanitation technologies, are

carried out at the national level in some countries and at the subnational
level in others, we have grouped these actions together in this table, on
the assumption that they would be assigned to the responsible parties
within a given country. Actions that are typically exclusive to national
governments, such as the carrying out of national planning processes,
have been noted with an asterisk.
Bilateral and multilateral development assistance agencies, regional development banks, and donor agencies and countries. As stressed in chapter
13, the task force is unanimous in its belief that target 10 will not be
reached unless there is a deliberate commitment by donors to increase
and refocus their development assistance and to target sufcient aid to
the poorest low-income countries. If the target is to be reached, therefore, fundamental changes by the bilateral and multilateral development agencies, regional development banks, and donor agencies and
countries will be required, as detailed in table 14.2.
The United Nations system. As emphasized in previous chapters, the
United Nations system organizations and their member states must
ensure that the UN system with its international partners provide
strong and effective support for the achievement of the water supply
and sanitation target and for water resources management and development. The actions that have to be taken by the United Nations system
organizations and their member states are outlined in table 14.3.
Other national and international actors. The actions to be undertaken by
other key actorsservice providers, civic and community organizations,
international networks and partnerships, and research organizations
are outlined in tables 14.414.7.
Other important actions that should be undertaken by all actors on a
continual basisboth during the Millennium Development process and
beyondare identied in table 14.8.
The task force recommends that all organizations engaged in the effort to
achieve the Millennium Development Goalsfrom national and subnational
governments to donors and NGOsshould themselves prepare an operational
plan to focus their support on the achievement of the Goals. The Water Supply and Sanitation Collaborative Council, for instance, has undertaken such
an exercise.
There is still time for the world as a whole to meet target 10but only
just. 2005 is a critical year; it must be the start of a decade of bold action
and swift progress. If the global community fails to act urgently, target 10
will be nothing more than a broken promise, another missed opportunity. But
if stakeholders at the community, national, and international levels can join
together in this common cause, the heartbreakingly simple dream of safe water
to drink and private, clean sanitation to use can become a reality for literally
176
Part 3
Table 14.1
Priority actions
for national and
subnational
governments
To reach target 10
Immediate priority actions
Short-term priority actions
Medium-term priority actions
Ensure that water

are included in national
planning processes,
especially poverty
reduction strategies.
Monitor changes over time

to gauge the effectiveness
of interventions and the impact of policy reforms and
investments at national
and subnational levels.

Undertake assessments
of water and sanitation
infrastructure endowments
and decits.
Remove barriers to service

provision in unregularized
areas.
Create a national-level
institutional home for
sanitation.
Ensure that appropriate,

exible standards for
water, sanitation, and
wastewater treatment technologies are in place.
Initiate policy reforms that
improve the nancial and
technical sustainability
of water and sanitation
service provision, such as
tariff reforms, ring fencing, and adequate support for ongoing operations
and maintenance.
Shift principal control

over water and sanitation
planning and service
delivery to local
administrations, including
budgetary authority.
Initiate policy reforms to

attract nancing to and
facilitate efcient use
of human and nancial
resources in water and
sanitation service delivery.
Support decentralization by retaining strong

oversight and support
functions, particularly with
respect to ensuring access
to services by poor households.
Provide funding to support

community mobilization
and organization for actions towards the water
and sanitation targets.
Obtain current, accurate

information about the
characteristics of unserved
households, so that
appropriate policies to
expand access to these
households are pursued.
Review and modify subsidy
policies as necessary to
ensure that improved water
and sanitation services are
affordable to the poor, and
subsidies are provided only
to low-income households.
Prioritize activities and

programs that raise the
prole of and demand for
improved sanitation.
Initiate policy reforms that

improve the accountability
of service providers, such
as the establishment and
funding of credible regulatory institutions, reform
of civil-service legislation,
and limiting political interference in decisionmaking.
To improve water resources management for all the Goals

Support Goals-based planning and policy development by an integrated

approach to land, water,
and ecosystems.
Use the action target

set by World Summit on
Sustainable Development in Johannesburg
for countries to develop
integrated water resources
management and water efciency strategies by 2005
as an opportunity to infuse
Goals-planning processes
with consideration of water
resources.
Develop a coherent approach toward deciding on

the investments in water
resources infrastructure
and management needed
to meet the Millennium
Development Goals.

Dene and promote strategies that will contribute to

multiple Goals and avoid
strategies that create
conicts among them.

of interventions and the
impact of policy reforms
and investments at
national and subnational
levels.
Disseminate small-scale
water technologies to
provide livelihoods to small
and landless farmers, while
addressing the hunger and
environment Goals.
Reduce the vulnerability of

communities to water-related natural disasters by
land reform, infrastructure
construction for water storage and ood protection,
and improved land-use
planning, including slum
upgrading.
Invest in community-based
natural resource management, including urban
agriculture, for hunger,
poverty, and environment
Goals.
Chapter 14
Table 14.2
Priority actions
for bilateral
and multilateral
development
assistance agencies
Priority actions for the

United Nations system
177
Increase current aid in the

water and sanitation sector
to levels commensurate with
the costs of attaining the
water and sanitation target
in the poorest countries.
Redirect aid to the poorest

countries and, within
countries, toward programs
that provide basic services
for poor households.
Prioritize investments in
basic sanitation and hygiene.
Reform aid procedures,

so that aid supports
policy reforms and
infrastructure investment
simultaneously, thereby
enhancing institutional and
policy frameworks while
expanding services.
Table 14.3
An operational plan
Increase funding to Joint

Monitoring Programme
and refrain from setting
up parallel structures.
Strengthen UN country
team efforts to provide
technical and capacitybuilding support
to governments.
Effectively coordinate
actions at the country
level, including
harmonization of
procedures and joint
programs, both within
the UN system and
with development
banks and bilateral
donor agencies.
Support the Joint

Monitoring Programme
as the key global
mechanism for
monitoring sustainable
access to water
and sanitation and
provide it with the
necessary resources
to carry out its work.

Substantially accelerate
the process for making
aid available, and
simplify the procedures
for allocating aid.
Support initiatives that

seek to encourage
more open and frank
discussion of sanitation
needs and practices.
Prioritize investments in
programs that help crowd
in community and private
resources to benet the
poor, as well as initiatives
that have the potential
to yield results at scale.
Use the upcoming

second Water Decade,
200515 (Water
for Life), to mobilize
international awareness
and political commitment
to sound water resources
management and
expansion of water and
sanitaiton services to
meet the Millennium
Development Goals.
Promote and nance

research and
development that
fosters innovations in
appropriate technologies,
social marketing, and
institutional arrangements
that improve access to
services by the poor.
Promote initiatives
that address
multiple Millennium
Development Goals.
Support, where useful,

the creation of new,
regional-level multilateral
donor mechanisms
such as the African
Water Facility.
Expand monitoring efforts

to include information on
the actions and investments
undertaken by the international
community toward meeting
the Goals, as well as on the
impacts of those activities.
Develop clear mechanism

to provide leadership and
strategic guidance to the
international community.
Mandate UN-Water to
periodically report through
World Water Development
Report on progress in water
resources development
and management for the
Goals, including progress
on the development
of integrated water
resources management
strategies by 2005.
Ensure the independence

and adequate funding of the
Advisory Board on Water
and Sanitation as a means
of achieving high-level
strategic focus among the
international community.
Strengthen UN-Water and

World Water Development
Report and provide with
greater funding to fulll
these roles successfully.
Focus the Secretary-Generals

and Sanitation on providing
high-level policy commentary
on progress toward the water
and sanitation target.
Reform monitoring
systems such that they
measure access to
sustainable services,
rather than the presence
of particular infrastructure.
Support the use of

scientic sampling and
household surveys for water
and sanitation monitoring.
Ensure that data collected

in global monitoring are
widely disseminated in
user friendly formats.

seek to encourage
more open and frank
Use the upcoming second

Water Decade, 200515
(Water for Life), to mobilize
management and expansion of
water and sanitation services
to meet the Millennium
Development Goals.
Ask the Secretary Generals

and Sanitation to comment
independently and boldly on
developing country, donor
country, and UN system
practices, and produce a
periodic, brief, focused,
high-prole report with
pointed recommendations.
178
Part 3
Table 14.4
Priority actions for
service providers
Support and lobby for

policy reforms in water and
sanitation subsidies, so
that benets are targeted
to poor households.
Support and lobby for

policy reforms in water and
sanitation tariffs, so that
service provision becomes
nancially sustainable.
Table 14.5
civic and community
organizations
Seek out opportunities

for partnerships with civic
organizations that can
improve access to water
and sanitation services
by poor households.
Revise budgets and

institutional incentive
structures, so that
sustainable operations
and maintenance of
installed infrastructure
receives sufcient
priority and resources.
Prioritize activities and

programs that raise the
prole of and demand for
improved sanitation.
Use accurate
informationthe end
product of reliable
monitoring effortsas
a powerful advocacy
tool for change.
Develop strategies for

encouraging more open
and frank discussion
of sanitation needs
and practices.
Seek out opportunities

for partnerships with
service providers that
improve access to water
by poor households.
Table 14.6
Raise public awareness

of the decits in coverage
and quality of water supply
through public statements,
articles, events, celebrity
endorsements, and other
innovative strategies.
Test, rene, and publicize

effective strategies for
service delivery to the poor
that have the potential to
yield results at scale.
international networks
and partnerships
Collectively strengthen
and rationalize efforts
and align them towards
the achievement of the
Goals while at the same
time taking steps to
ensure accountability
to the communities of
the developing world.
Use accurate information
the end product of reliable
monitoring effortsas
a powerful advocacy
tool for change.
Use the upcoming

second Water Decade,
200515 (Water
for Life), to mobilize
management and
expansion of water and
sanitation services to
meet the Millennium
Development Goals.
Publicly support policy
reforms that better
target subsidies to poor
households, promote
sustainability of service
delivery, and heighten
accountability of service
providers to households.
seek to encourage
more open and frank
Pursue innovative
strategies, including
lower cost appropriate
technologies, to expand
services to unregularized
settlements.
Help to hold service

providers and governments
accountable for expanding
and improving water
to the poor through
audits, public information
campaigns, etc.
Help to identify strategies

for ensuring access
to services by poor
households while also
maintaining nancial
sustainability for
service providers.
Share information and

experiences with service
providers, as well as with
subnational and national
governments, seeking
to better understand
the characteristics of
and obstacles faced by
unserved households.
Help to hold service

providers and governments
accountable for expanding
and improving water
to the poor through
audits, public information
campaigns, etc.
Package and disseminate

information collected in
national and international
monitoring efforts such
that it is accessible to
community organizations,
the media, and the
general public.
Explore ways to use

the new UN ECOSOC
afrmation of the Right
to Water to inuence
national policy on water
and sanitation.
Chapter 14
Table 14.7
Priority actions
for research
organizations
Table 14.8
all actors throughout
the Millennium
Development process
and beyond
An operational plan
179
Better document and

communicate the
economic benets of
improved water and
sanitation services.
Support the development

of appropriate technical
standards for water
supply, sewerage, and
sewage treatment.
Conduct research and

disseminate ndings on
effective strategies for
providing sustainable
water supply and
sanitation services in
persistently challenging
settings (unregularized
urban communities, small
towns, poor rural villages).
Increase research
and development
on technologies and
institutional innovations
aimed at meeting several
Goals simultaneously
and reducing tradeoffs
among the uses of
water resources to meet
the various Goals.
Develop new sanitation

technologies to
reuse wastewater for
periurban agriculture.
Develop a conceptual
framework for dening
and measuring the
contribution of water
resources development
and management
to the Millennium
Development Goals.
Carry out research

and development of
appropriate, affordable
sanitation technologies.
Prepare an operational plan that outlines what they will do during the period
200515 to help achieve target 10 and the development and management
of water resources for the Millennium Development Goals.
Maintain a focus on sustainability to ensure that gains made in expanding access

to water and sanitation services and improving water resources management during
the Millennium Development process will be maintained in the long term.
Incorporate gender considerations into policy recommendations and program design;

address gender biases within their own institutions. Take measures to reduce
corruption at all levels, whether in donor organizations, international agencies or
companies, or public, private, or civic institutions in developing countries.
Take measures to reduce corruption at all levels, whether in donor organizations, international
agencies or companies, or public, private, or civic institutions in developing countries.
Appendix 1
This appendix briey describes some case studies that have been mentioned
in the report to guide the strategies for achieving target 10. These case studies
demonstrate a variety of approaches that appear to be working. They include
community management of rural water and sanitation projects, improvements
in service for the urban poor, and increasing urban coverage for both the poor
and the nonpoor. We will, however, start with a case that shows what is being
done to reach the water target.
Turning the right to water into a reality: the South African
experience
This case study illustrates the importance of political will in introducing a radical
policy of free access to basic water supply, thereby helping South Africa to make
rapid progress toward the Millennium Development target for water (drawn from
World Bank 2002).
In 1994, 15.2 million out of South Africas population of 40 million lacked
access to basic water supply (dened as 25 liters per person per day of water
of acceptable quality within 200 meters from home). Of these, 12 million
lived in rural areas. In addition, 20.5 million lacked access to basic sanitation
(dened as a ventilated, improved pit latrine or its equivalent). South Africa
has used a combination of instruments to turn things around. These include
introduction of policy reform with an accompanying legislative framework;
devolution of responsibility for water supply and sanitation from the national
level to local governments, using community-based approaches; launching of
a capital works program that has provided infrastructure to meet the needs of
more than 7 million people; and the introduction of free access to basic water
supply, through which water has been provided for some 27 million people as
181
of July 1, 2002. As a result, South Africa hopes that within seven more years
all residents would have access to basic water supply.
This remarkable success in increasing access to basic water supply has been
underpinned by a strong political leadership and support from the national
government, which made it possible to devote so much funds to support the
capital works program and the free basic water policy. An important contributory factor has been the existence of a very substantial institutional and
technical capacity that was already in place before 1994. The existence of an
appropriate institutional framework facilitated the introduction of legislation
needed for the program. Finally, the level of economic development in South
Africa supported the policy of free access to basic water. This case is not necessarily applicable to less developed countries, unless they benet from new and
creative concessional funding from external sources.
Community-led total sanitation with no subsidies: a spreading
revolution
Community-led total sanitation is a revolutionary low-cost approach to rural sanitation, which relies on hands-off facilitation and community appraisal, analysis,
and action, without any subsidy for hardware. In a matter of often only weeks,
communities transform themselves from open defecation to total sanitation. Community-led total sanitation is spreading in Bangladesh, India, and Cambodia,
and is starting in Indonesia, Mongolia, Nepal, Uganda, and Zambia. It shows
potential to become an exponentially self-spreading movement.1
The methodology of community-led total sanitation by rural communities was pioneered in 2000 by Kamal Kar and colleagues with WaterAid and
VERC, a nongovernmental organization (NGO) in Bangladesh. It spread there
with support from CARE, PLAN, World Vision, other NGOs, and the government. The Water and Sanitation Program of the World Bank has been supporting and promoting community-led total sanitation in South and Southeast
Asia. By mid-2004 community-led total sanitation had spread to more than
2,000 communities in Bangladesh, to several hundreds in India through the
government of Maharashtra, and to Cambodia through Concern Worldwide.
Starts had also been made in Indonesia, Mongolia, Nepal, Uganda, and Zambia. The impact has been dramatic drops in diarrheas and medical expenditures and major gains in well-being for women, children, and men.
In community-led total sanitation community members are facilitated to
do their own appraisal of open defecation. Facilitators do not teach, educate,
advise, criticize, preach, or tell people what they should do. They simply convene and facilitate appraisal and analysis. Community members together map
their households and where they defecate. They then stand, smell, and discuss in their defecation areas; calculate the amounts of feces produced; analyze pathways of contamination through dirt, ies, and animals; and estimate
182
Appendix 1
how much each person ingests each day. Disgust, shame, religious precepts for
cleanliness, and self-respect then commonly combine in a decision that open
defecation must stop. People dig holes and construct homemade pit latrines
according to local designs. To achieve total sanitation quickly, some latrines
are shared. Those who are better off often help the poorer and landless with
space and materials. Communities put up boards at the entrances to their villages proclaiming proudly that they are totally sanitized. The resulting social
solidarity provides a base for further collective action. Communities evolve
their own systems of monitoring and penalties for default. A social ratchet
effect evidently sustains total sanitation once it has been established through
such a process.
There are no standard designs. An explosion of innovative, low-cost models designed by community engineers has taken place. Many people start with
very simple temporary structures of bamboo, sacking, and the like. In Bangladesh the cost of purchased materials can be less than $1. Progressive improvements then follow. Some start higher on the sanitation ladder and construct
toilets in their houses. Local traders meet new demands for pans and accessories. Latrines are evacuated when full or are covered over and planted with
trees, and new latrines are dug or constructed.
For community-led total sanitation to ignite, two conditions admit no
compromise. First, there must be no policy, practice, or even rumor of subsidies for hardware. Community-led total sanitation has been inhibited and
slowed by a national survey of sanitation, which led to expectations of subsidy.
Community-led total sanitation cannot spread well, if at all, when there is
hope of hardware subsidies. Second, facilitation by outsiders must be handsoff, enabling community members to do their own appraisal, calculations, and
analysis, not prescribing but at most, when asked, telling them about practices
in other communities. To ensure these behaviors requires careful hands-on
training and mentoring.
Community-led total sanitation has been spread by not just by NGO facilitators but increasingly, with light external support, by community consultants
and communities themselves. Community consultants have their own effective
ways of facilitating, drawing on their experience of total sanitation in their own
villages. Communities themselves have become lead institutions: CARE Bangladesh has pioneered a low-cost approach, also adopted by the government of
Maharashtra, in which a community is rewarded for every other community
totally sanitized through its efforts. Following the lead of Maharashtra, the
government of India has changed its guidelines from providing an up-front
hardware subsidy to households to offering a scal incentive of a lump sum to
villages in which open defecation is assessed to have ended. Innovations such as
these can be expected to continue as the approach expands in scale.
Community-led total sanitation presents many challenges. It demands
shifts of mindset and policy as well as behavior:
183
From teaching and educating to facilitating the communities own

analysis.
From we must subsidize the poor to communities can do it.
From we persuade and motivate to its up to you, you decide.
From top-down standardization to bottom-up diversity (they
design).
From bigger budgets to lower budgets to allow more to be achieved.
For community-led total sanitation to realize its huge potential demands
changes in mindsets and behaviors away from the standard philanthropic (subsidize), professional (set high standards), and bureaucratic (demand big
budgets) approaches. Instead, supporters concentrate on lower-cost training,
facilitation, and support for community facilitators. If there are vested interests
and ingrained practices, they have to be confronted. The challenge to those
working in aid agencies, governments, and NGOs is to be consistent in making these big switches and to support sharing and learning across and within
organizations and countries. It remains to be seen which organizations and who
within them will have the vision, realism, and guts required. Continuous learning is needed about how and where spread occurs and how it can and should
be supported. But enough is already known to see that if community-led total
sanitation can become exponentially self-spreading, the scale of gains in wellbeing, for tens or hundreds of millions of rural people, will be enormous, and
can make a major contribution to all the Millennium Development Goals.
From central to local government and community-based
approaches to rural water supply: the experience in Ghana
This case study involved a shift from a supply-driven central government approach
to a demand-driven approach to rural water supply and sanitation. It also involved
a shift in the role of central government, from that of an implementer to that of a
facilitator, with greater involvement of the private sector, thereby introducing competition with consequent improvement in performance and reduction in the cost of
service provision (drawn from World Bank 2002).
It all started in 1990. Up to that time, one national public authority, the
Ghana Water and Sewerage Corporation (GWSC), was responsible for water
and sewerage services for both urban and rural areas throughout Ghana. During that period, most rural communities were served by boreholes equipped
with hand-pumps. The boreholes were drilled by the GWSC, donors, or NGOs
that also maintained them. There was only one private drilling company. The
drilling market was characterized by lack of competition. As a result, the average
cost of boreholes in Ghana was $9,000, compared with $3,000 in the United
Kingdom or the United States. Mobile crews were responsible for the maintenance. In these circumstances, only about 40 percent of handpumps worked at
any given time. There was no sense of ownership by the communities that were
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served by handpumps. So when handpumps broke down, people simply waited

for them to be repaired when the mobile repair crew reached their communities.
The situation was no better for piped systems that suffered long periods of supply interruptions because of breakdowns and maintenance neglect.
Beginning in the late 1980s, a number of institutional and policy reforms
were introduced. New legislation was introduced under which the GWSC
was replaced by the Ghana Water Company Limited (with responsibility for
urban water supply) and the Community Water and Sanitation Agency (with
responsibility for rural water and sanitation services). A new national water and
sanitation policy was also introduced to shift the approach to service provision
from a supply-driven one to a demand-responsive approach.
Under the new national policy, certain core functions were transferred
from central government to the local government and the communities. Ownership of water supply was transferred to the local governments and the communities. The private sector became increasingly involved in various aspects of
service provision. In one $20 million World Bank-nanced community water
and sanitation project implemented in 26 of the 110 districts in the country,
district assemblies constructed 1,200 water points and 29 piped systems. There
was a lot of private-sector and NGO involvement in the project. This included
four drilling companies and 32 NGOs and community-based organizations.
Several national and international NGOs were commissioned to train and
build the capacities of the district-level NGOs and community-based organizations. The success of this project has led to a follow-up $80 million, nineyear World Bank-supported project. One of the aims of the new project is to
shift from individual donor-supported water supply projects to a sectorwide
approach under which all external support agencies would be encouraged to
pull their resources into a single national water-sector program.
Several factors have helped to make this reform successful. Foremost was
the speed of implementing the reform process. It was not rushed. Instead, a
gradual approach was followed in the transfer of responsibility from the central level to the local government and community level. The transfer rate was
matched to the rate of technical capacity building and support from the central
level in the areas where local capacity was decient. Second, the involvement
of the private sector was accompanied by an incentive structure under which
contractors were paid for their outputs rather than their inputs. Finally, the
decentralization of service provision was facilitated by the general process of
decentralization taking place within the country at the time.
Unbundling between different zones in an urban area:
experience from Thailand
This case study shows how unbundling of service facilities can be used as an instrument
for reducing the constraints of technologically complex, large-scale urban sewerage
185
projects. The project in Bangkok also reduced the lumpiness of investments in urban
sanitation, thereby removing barriers to access to urban sanitation services.
Bangkok, the capital of Thailand, is a city of 10 million people. In 1968,
the Bangkok Metropolitan Administration prepared a wastewater master plan
for the entire metropolitan area. Though technically sound, the plan was
found to be prohibitively expensive and was shelved for 16 years. In 1984, the
master plan was revised under a Japanese (JICA) technical assistance program.
Instead of a single centralized program, the inner city was divided into ten
sewerage zones, each with an independent collection and treatment system.
The revised approach is an example of horizontal unbundling between different zones of an urban area. Sanitation investment in each of the ten zones
is lower than the investment for a single project in the whole city. Each zone
project is also technically simpler than the citywide project. These two impacts
of unbundling have made it possible for the Bangkok Metropolitan Administration to implement various sanitation projects in different zones of the city,
using a more affordable, phased investment program.
Unbundling, coupled with greater responsiveness to demand, helps
to remove major barriers to the expansion of coverage. Yet they still do not
address the question about where the boundary between public and private
infrastructure should be drawn. Demand for improved sanitation is almost
always based on perceived private benets. These are much lower than the total
benets from citywide sanitation investments, which are known to include
externalities or benets that are realized beyond the boundaries of the direct
user of sanitation services. Experiences in Pakistan and Brazil show how these
issues have been addressed.
Reaching the urban poor with improved sanitation: the
experience in Pakistan
This case study illustrates a tripartite partnership between community, government, and an NGO in the provision of improved sanitation services to a lowincome urban fringe community. It also illustrates a stepwise approach to urban
sanitation, in which the technology is adapted to the technical capacity and nancial means of the beneciary community. Its salient features include the use of such
instruments as unbundling, community management with social intermediation,
and internalizing the nancing of community infrastructure for sanitation.
Orangi is a large katchi abadi (or low-income informal settlement) in Karachi. It has a population of more than 1 million. The Orangi Pilot Project
(OPP) is a nongovernmental organization, and sanitation is one of four projects the NGO is undertaking in Orangi.
After years of research and learning by doing, the OPP has developed a
model of low-cost sanitation in which government, the community, and the
NGO are treated as partners, and sanitation development takes place at two
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Appendix 1
levels: an internal component level and an external component level. The

internal component has three sequential sanitation subcomponents: an inhouse sanitary latrine or toilet, a lane sewer that collects sewage from houses
along a lane in the community, and a neighborhood sewer that collects sewage
from the lane sewers in a neighborhood. The last two subcomponents together
are equivalent to what is known as a feeder sewerage system. The external
component has two subcomponents: trunk sewers that collect sewage from
neighborhood sewers and a sewage treatment plant for treatment and nal
disposal of the sewage from the trunk sewerage system. These two subcomponents may together be regarded as a trunk sewerage system.
The OPP sanitation project started with the NGO approaching the community and urging residents to form lane organizations and to elect a lane manager.
Once this was done, technical support was provided to the lane organization to
construct a lane sewer to collect waste from their houses. It had been hoped that
the government would then step in and provide a sewer network to collect the sewage from the lane sewers. This did not happen. So the lane managers from each
neighborhood came together and pooled their human and nancial resources to
construct neighborhood-level sewers to collect the wastes from the lane sewers.
Initially, the sewage from the neighborhood sewers was discharged into
nearby natural drains. But eventually, the Karachi Municipal Corporation and
the District Municipal Corporation agreed to nance the construction of a
trunk sewer to collect the waste from the neighborhood sewer. This meant
that there was a transitional period during which the untreated sewage from
the Orangi community polluted the local environment. However, this was
corrected when the public component of the sewerage system was installed.
Without the price of the transitional environmental pollution, the community
would not have gained access to basic sanitation, and the environmental pollution would have continued all the same through other means.
According to S. Akbaar Zaidi, the OPP model has been replicated in 59
settlements in 11 cities (Zaidi 2000). It has also been reported that the principles of the model are being applied to projects in Nepal, Central Asia, South
Africa, and Sri Lanka (Hasan 2000).
The OPP model allows for vertical unbundling between the internal and
the external sewer components, as well as horizontal unbundling between parallel neighborhoods. A feature of the OPP model is that the normal boundary
between private and public provision is extended from the household level to
embrace the entire neighborhood. That is to say, the neighborhood sanitation
infrastructure is a public facility that is privately and collectively owned by those
in the neighborhood. Thus, its ownership is private, but its use is public. Under
this arrangement, investment and operational responsibility within the neighborhood is now treated as internal development and is left to the community. The
responsibility for investment, operation, and maintenance beyond the neighborhood is treated as an external responsibility and is assigned to the public utility.
187
This denition of what is private and what is public has a number of

attractive features. The entity that expresses demand to the public utility is
not the household; it is the community. This reduces the number of respondents for demand assessment, thereby reducing the transactions cost for such
assessments. Furthermore, this denition makes it possible for the neighborhood to be used as the channel for expressing the voice of households,
thereby giving the households bargaining powers. In addition, the denition
expands the responsibility for nancing of private infrastructure beyond the
household level. Financing of infrastructure within the neighborhood is thus
internalized.
Another feature of the approach is that it denes a clear set of target groups
that would serve as partners, along with social intermediaries, in the internal
development of sanitation projects. A similar denition of the private-public
boundary has also been used in the Brasilia condominial model.
A community-based approach to urban sanitation: the
condominial model in Brazil
This case study illustrates a shift from conventional sewerage technology to a technically equivalent, lower-cost alternative known as the condominial system. The
lower cost arises from the use of sound technical standards based on current scientic and technical research, as well as current experience and innovation, rather
than a reliance on the 100-year-old concepts inherent in conventional sewerage.
Community participation is an integral part of the project, as is the joint ownership
of community resources, such as the sewerage system within a condominial block.
This feature of unbundling is analogous to ownership of neighborhood-level sanitation infrastructure in the OPP model.
Brasilias model for supplying sanitation services to its 2 million residents
is the latest version of the condominial sewerage system. Developed in the
1980s in the state of Rio Grande do Norte by Jose Carlos Melo for low-income
communities, the system has now become a standard solution for entire urban
areas in Brazil, irrespective of residential income. The Water and Sewerage
Company of Brasilia has been using this version of the condominial system for
more than 10 years. Within the rst 8 years, 121,000 homes were linked to
the condominial system, using 1,300 kilometers of condominial branches and
more than 660 kilometers of public networks at average costs per person of $27
and per meter of sewer network of $16.
The basic planning unit in this model is the condominium. It is dened
as the urban block, square, or its equivalent. The residents of a condominium
dene its boundaries. They do so through an informal community organization. It is this block or condominium that is connected to the public sewer.
This is in contrast to conventional sewerage systems, where connection to the
public sewer is made directly to the individual house, a more costly approach.
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Appendix 1
The connection in the condominial system is made through the condominial branch sewer. Thus, the network within the condominial block is treated
as private infrastructure, and its investment costs are borne by the residents
of the condominial block, just as is the case for the OPP model in Pakistan.
The infrastructure beyond the condominial branch sewer, up to the treatment
plant, is treated as public infrastructure, and its investments are the responsibility of the public service provider. The cost of this system is, however, recovered from the sanitation charge.
The public network is divided into two parts, namely, a number of parallel
microsystems and a citywide system. The microsystems are dened by subdividing or unbundling the urban area into small natural drainage basins, each
with its own independent sanitation system, from collection to treatment and
disposal. The microsystems receive wastes from the condominial blocks and
either purify them within the corresponding microdrainage basin or feed them
into a citywide sanitation network. The microsystems can therefore be operated
as independent systems permanently or until such time that local or citywide
development imperatives make it necessary that they should be connected to the
citywide system. The citywide system receives ows from parallel independent
microsystems. In much the same way, there could be a regional system that
receives wastes from a number of parallel independent citywide systems.
Community participation is an integral part of the condominial model,
just as it is in the OPP model. Community participation in decisionmaking
and in community activities is viewed both as a right and as a duty of citizenship. It is viewed as a way of helping to nd solutions for the common interest within the block. Participation is also considered a process of negotiation
among interested parties to reduce costs, mobilize resources, and stimulate
community actions, including monitoring of jointly owned resources such as
the condominial sewerage.
The Brasilia example illustrates both horizontal and vertical unbundling.
The city sanitation system is subdivided horizontally into a number of parallel microsystems. Each of these microsystems is subdivided horizontally into
a number of parallel condominial blocks. In addition, the boundary for the
private component of the sewerage system extends to cover the block, square,
or equivalent. With this arrangement, sewage ows from households into a
sewer network within the condominium area and from there into a network of
micro-systems and eventually into a citywide system.
The Brasilia condominial model thus gives rise to a decentralized sanitation system with the possibility of interconnection into an integrated citywide
network of clearly identiable subsystems. The model has a lot of exibility; it
is demand-responsive and lends itself to service differentiation within different
condominial blocks and within different microsystems. It has good prospects
for overcoming most of the barriers to sustainable expansion of coverage in an
urban area. It is being replicated in a number of countries in Latin America.
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Its use, together with the concepts in the OPP model, holds very good promise
for achieving the Millennium Development target of improving access to basic
sanitation in many urban areas, large and small.
Tapping the strengths of spiritual organizations: the experience
in India
Religious organizations tend to have motivational and organizational skills that

make them highly effective in mobilizing followers and changing entrenched mindsets and habits. However, these strengths are not often appreciated or tapped for
community-based water and sanitation programs. This case study illustrates the
successful use of these skills in a rural sanitation project in the Medinipur District
of West Bengal, India (drawn from Chowdhry 2002; Sengupta 2001; UNICEF
1994, 2002a).
The Medinipur District rural sanitation project, also known as the Intensive
Sanitation Project (ISP), was launched in 1990. It involves a partnership among
UNICEF, state and district governments in West Bengal, a religious NGO (the
Ramakrishna Mission), and voluntary grassroots community organizations. It
is implemented by the Ramakrishna Mission, a development-oriented religious
organization established in 1897, with its headquarters at the outskirts of Calcutta, but heavily involved in social development and rehabilitation works in
India and abroad.
The project is designed to motivate people to move away from the age-old
practice of open defecation. Paradoxically, the practice of open defecation in
the area was based on the belief that defecation is unhygienic, and hence it is
best done far away from the home. As people used the open eld, however,
they were exposed to outbreaks of cholera and other excreta-related diseases
that occurred during rainy seasons. The project implementation strategy was
thus driven by a need to change mindsets and habits toward not just in-house
sanitation, but also a clean and hygienic living environment. Thus, hygiene
education was an integral part of the project.
The project has a three-tier organizational structure, with the Ramakrishna
Mission interacting both with state and district governments at the top and
also with cluster organizations, voluntary youth clubs, and beneciaries at the
community level. The organizational unit for the project implementation is the
community development block. There are 54 such community development
blocks in the project area, each with a population of about 150,000. Within the
community development blocks are voluntary youth clubs, more than 1,000 in
the project area. These are aggregated into a number of groups known as cluster
organizations. There are 11 such cluster organizations in the project area.
The mission involves the local community in each stage of the program,
especially in the delivery of sanitation messages, and strives to mobilize the
community and develop local human resources. Community mobilization is
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Appendix 1
done through trained motivators from the target communities. Its primary
goal is to create awareness of the importance of health and hygienic practices
through home visits, motivational camps, exhibitions, and such communication materials as ash cards, calendars, motivational kits, and audiovisual
materials. Sanitation messages are conveyed through writings on walls, video
and slide shows, and song squads. Training, especially the training of trainers,
is given a high priority in the project. All categories of workers are given appropriate training related to their work.
In 1990, barely anyone in the villages of West Bengals Medinipur District had household latrines. But just a decade later, roughly 80 percent of the
families in Medinipur possess latrinesreducing exposure to communicable
diseases of excretal origin and making Medinipur a role model for other parts
of India.
Local involvement was also critical in the physical development of the
latrines. Each component of the latrine was produced at production centers
where local women were trained to manufacture the sanitary wares. A range
of cheap and effective sanitation technologies, such as single-pit latrines, were
made available. To help persuade reluctant villagers to switch to latrines, representatives of the production centers were enlisted to motivate and prepare
households for such a change. These representatives received an incentive for
every household they could motivate.
To date, approximately 1.2 million latrines have been delivered through
the program throughout West Bengal, and another 1.5 million have been built
through other programs. The impact of widespread latrine development has
been accompanied by a remarkable reduction in illnesses and deaths associated with diarrheal diseases. The Intensive Sanitation Project in Medinipur has
proved to be a successful peoples movement and has helped develop a sense of
pride and belonging among the villagers.
The Sulabh sanitation movement in Indian communities
This case study outlines a successful, low-cost sanitation approach developed and
implemented by a nongovernmental organization, Sulabh International Social
Service Organisation. The program, named Sulabh Shauchalaya, means easy
access to sanitation. 2
Sulabhs approach to improved sanitation is twofold: innovative modications of an existing low-cost technology, and equally innovative institutional
and social programs, combining sanitation objectives with social reform. Sulabh
popularized the use of the pour-ush system in India, rst as a domestic latrine
and second as a public pay-for-use facility. Both have been very successful as
a result of the institutional arrangements used by the organization.
The pour-ush technology has many advantages. It is affordable, even by
the poorer members of society, as there are designs to suit different levels of
191
income. Flushing requires only 2 liters of water, instead of the 10 liters needed
by other ush toilets. It is never out of commission since, with the twin-pit
option, one pit can always be used while the other one is being rested to allow
its contents to decompose. The latrine can be built with locally available materials and is easy to maintain. It has a high potential for upgrading because,
while it is a stand-alone, on-site unit, it can easily be connected to a sewer
system if and when one is introduced in the area. The toilet is also culturally
acceptable, inasmuch as it is ushed by the water used for ablution, and its
water seal makes it odorless and insect-free.
So far, more than 1,000,000 units have been constructed (or substituted
for existing unhygienic latrines) in houses, and 5,500 have been installed in
pay-for-use public toilets since the organizations beginnings in 1970. A key
aspect of Sulabhs program is its inclusion of facilities for bathing and doing
laundry. Their public toilets are staffed by attendants 24 hours a day and supply powdered soap for hand washing, bathing, and laundry. Free services are
offered to children, the disabled, and the poor. This is very important for the
homeless and the very poor, who live under crammed conditions. More than 10
million people use the complexes every day. Some special facilities have also provided telephone services and primary healthcare. Another technological aspect
of the program is the modication of the pour-ush toilets for the production
of biogas from human excreta for electricity generation, cooking, and lighting.
Sulabhs research and development activities are geared to practical solutions for
solid and liquid waste disposal, including recycling and resource recovery.
Despite the virtues of the technology, the Sulabh program might not have
been so successful had not public awareness and community participation been
considered critical aspects in the goal of improving sanitation. Among isolated
populations, unlikely to feel responsible for wider environmental conditions,
the Sulabh International Social Service Organization has undertaken educational efforts to help reverse this frame of mind and instil strong community
awareness. The approach includes door-to-door campaigns by Sulabh volunteers and workers who persuade people to convert from bucket latrines. Once
approval is gained, the organization takes responsibility to relieve the beneciary of the bother of constructing the twin-pit, pour-ush toilet. Sulabh also
educates people on use and maintenance of their new latrine and promises to
x construction defects and solve technical problem at no cost. After construction, service is provided, and problems in use and maintenance are resolved by
locally posted Sulabh workers.
The program includes technical training to local people to enable them to
construct more latrines themselves. In rural areas, latrine builders are also trained
in such elds as hand-pump repair, brick laying, social forestry, and biogas production. The organization estimates that 50,000 employment opportunities have
been created through the Sulabh Shauchalaya program. Sulabh also helps local
communities set up, operate, and maintain the community toilet complexes.
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Appendix 1
Another key institutional aspect of Sulabhs program is that the NGO has,
in some municipalities, taken over these complexes from the city ofcials for
a contracted period of 30 years, relieving the municipal authorities of the task
of operating and maintaining them. This has vastly improved the quality of
facilities available to users. Often these comfort stations are the cleanest ones
in town, even in major cities such as Delhi, Bombay, Calcutta, and Madras.
Sulabhs experience shows that, where nancial resources are constrained by
central administrations, functions can effectively be delegated to grassroots
and community organizations.
Financing rural water supply and sanitation in China
Financing for rural water supplies and sanitation in China comes from many
sources, including users, township enterprises, village committees, and national and
provincial governments, as well as foreign loans and grants. Users, the largest source
of nancing, are expected to pay a signicant share of capital costs and all operation
and maintenance costs, including servicing of World Bank project loans.3
The Chinese government has made it a priority to invest in water and
sanitation, aiming for 95 percent of the rural population to have access to
improved water supplies, 70 percent to have piped water supplies, and 65 percent to have sanitary latrines by 2010. China is well on its way to meeting these
goals with signicant gains in coverage over the past 15 years. World Bank
and other assistance have aided these efforts. The World Bank China Rural
Water Supply and Sanitation Program has initiated projects aimed at serving about 23 million people in 18 provinces. China differs signicantly from
most developing countries in that there is little history of the central government providing large subsidies for the nancing of rural water supply. Instead,
there is greater emphasis on cost-sharing by provincial, county, and community institutions. This context proved to be compatible with the World Banks
development of a signicant cost-recovery model, where capital, operation, and
maintenance costs, including repayment of loans, are ultimately repaid by the
rural beneciary.
One concern regarding cost-recovery programs is that those served are often
not the very poorest, whose needs are greatest. In China, the national policy is
to use government funds for increasing coverage through providing basic levels
of service to those in greatest need and to use external funds, such as from
the World Bank, to provide greater levels of service, through piped water supply systems, where demand exists. Within the World Bank-assisted projects,
however, the more remote and scattered areas are also provided water supply
systems similar to the ones covered under the government programs: handpumps, rainwater collection systems, and small tube wells. The cost-recovery
policy for the basic level of schemes in both World Bank-assisted and government programs is the same: full labor contribution and full responsibility for
193
operation and maintenance costs. Debt servicing is not passed on to the consumers of these schemes with lower service levels.
The functional level of project management is the township water-supply
plant. The cost of running the water plant, as well as the debt servicing cost, is
met from those beneting from higher-service-level schemes. The water plant
collects water fees from households, each of which has a metered connection.
Water tariffs are set by the plant management and the County Price Bureau, and
prices are raised when necessary to cover increased operating costs. The tariff
calculation is comprehensive and includes the cost of electricity, salaries, watersource fees, depreciation, debt servicing, interest on debt, overhead, and taxes.
To protect consumers interests, China has developed an effective price
regulatory system at the county level. Once the proposed tariff has been calculated at the water plant, it is sent through the County Project Ofce (CPO)
to the County Price Bureau (CPB) for approval. The CPB reviews the calculation, holds discussions at the water plant and CPO levels, then visits the concerned villages and holds public hearings with the consumers to determine the
affordability of the new tariff. In some cases, the Price Bureau asks the water
plant to revise its tariff.
Cost-sharing by users promotes nancial sustainability of water-supply systems, but many observers worry that poor households may not be able to afford
cost-recovering tariffs. In most cases, the costs appear to be affordable. As an
example, households supplied with water from the project typically consume 3
cubic meters a month. At a tariff of 2 yuan per cubic meter, the annual water
bill comes to 72 yuan. Assuming an annual per capita income of about 2,000
yuan in rural China, this works out to 3.6 percent of annual income.
In 2002, 868 million Chinese rural residents92 percent of the totalhad
access to improved water supplies. Of these, 57 percent had access to piped water
systems, a 43 percent increase over 1985. In addition, 49 percent of rural households had sanitary latrines, 41 percent more than in 1993. Government programs
have dramatically increased awareness of health care and hygiene issues among
rural populations. Such progress has greatly improved the lives and health of
rural residents and promoted rural economic and social development.
The scaling up and achievements of rural water supply and sanitation in
China are closely linked to the countrys political willingness to chargeand
users willingness to paycost-covering water tariffs. There are other factors, as
well, including the countrys stable political situation, rapid economic growth,
commitment to rural residents, and the fact that external funding is only a
small percentage of Chinas nancial resources. The question of whether Chinas
nancing policy can be replicated is not an easy one to answer, but there are
lessons to be learned in the governments willingness to price rural water supply
services at nancially sustainable levels, a condition that is not met in many other
countries. Perhaps this case can help demonstrate to decisionmakers in other
countries that cost recovery in rural water supply and sanitation can be realized.
Notes
Preface
1. These denitions of sustainable access to domestic water supply and basic sanitation are considerably broader than those used by the Joint Monitoring Programme for
Water Supply and Sanitation, which is administered by the World Health Organization
and the United Nations Childrens Fund. The United Nations has charged the Joint Monitoring Programme with monitoring progress toward target 10.
Chapter 1
1. UN Millennium Project www.unmillenniumproject.org.
2. World Summit on Sustainable Development www.Johannesburgsummit.org.
3. Some text in this section and the section that follows titled, The institutional context, was drawn directly from the annex of UN WEHAB Working Group 2002.
4. UN Millennium Development Goals www.developmentgoals.org.
5. Much of this section was drawn directly from UNDESA 2002b. Special thanks to
task force member Manuel Dengo of UNDESA for allowing us to incorporate sections of
this text verbatim.
Chapter 2
1. The remainder of this section draws extensively on Water Governance for Poverty Reduction (UNDP 2004). Special thanks to task force member Ingvar Andersson of
UNDP for allowing us to incorporate sections of this text verbatim.
2. All dollar values in this report are U.S. dollars unless otherwise indicated.
Chapter 3
1. A survey instrument being prepared by the WSSCC task force gives further elaboration of the meanings of these two aspects of improved water supply.
2. Dened as domestic wastewater resulting from bathing and washing of dishes and
clothes in the home.
3. For example, the Public Affairs Center (PAC) in India has conducted a survey of
36,500 households regarding basic services. Their data indicate a gap, sometimes wide,
Notes
195
between the availability of a service and its satisfactory functioning (for example, water
pumps installed in villages, but not functioning).
4. WHO/UNICEF JMP www.wssinfo.org.
5. If possible, coverage estimates are based on all available national household surveys
and censuses. All available surveys and censuses are plotted on a time scale. A linear trend
line, based on the least-squares method, is drawn through these data points and determines
the estimates for 1990 and 2000. In case household surveys and censuses are not available,
coverage data given through the GWSSA 2000 questionnaire is used. In the future the linear trend line might be replaced by a curvilinear trend line. For a more detailed description
of the methodology, please refer to WHO/UNICEF JMP 2000.
6. To be used in the calculation of coverage data for a country, surveys must meet certain criteria: The survey needs to be representative of the entire country; it needs to be well
documented; and details about the data should be available. In the JMP approach, coverage
data are based on the type of services used, so if a survey only gives one total gure for people
with access, this survey cannot be used to calculate the coverage estimates because it is not
clear whether this access meets the JMP standard of improved. However, details of surveys,
even those not used, have been included in the country les and are visible in the graphs for
purposes of comparison. Examples of valid surveys are the Demographic and Health Survey
of ORC-Macro (funded by USAID) (see www.measuredhs.com), UNICEFs Multiple Indicator Cluster Survey (see /www.childinfo.org/MICS2/MICSDataSet.htm) and some of the
World Banks Living Standard Survey (see www.worldbank.org/lsms/). Many censuses have
also been used, but sometimes their data are given with insufcient detail.
7. The Technical Advisory Group is made up of individual experts from academic
institutions and civil society, plus representatives of organizations involved in water and
sanitation and data collection, including UN-HABITAT, ORC Macro, the UN Environment Programme, the Environmental Health Project of the U.S. Agency for International
Development, the World Bank, the Water Supply and Sanitation Collaborative Council,
and the Millennium Project.
Chapter 4
1. Progress in Bangladesh must be evaluated in the context of the signicant problem
the country is currently facing with arsenic contamination of groundwater supplies.
2. Special thanks to task force member Jennifer Davis, who devised the community
typology outlined in this section and who wrote the text that follows.
3. It should be noted that freshwater scarcity is one supply issue that receives limited attention in the typology. The International Water Management Institute estimates
that 30 percent of the worlds population lives under conditions of physical water scarcity
(that is, without enough water to meet minimum industrial and domestic needs and provide for present levels of food production). Scarcity is also an important explanation for
lack of access to water supply in many local-level analyses. Overall, however, the association between physical water availability and coverage is not as strong as, for example, the
(inverse) association between poverty and access.
4. Water quality is, of course, a concern when households use water primarily intended
for irrigation. Installing handpumps along irrigation canals as described above is just one
strategy for improving the quality of water to levels needed for domestic purposes; the
water is drawn through a natural sand lter before being pumped and captured. Point-ofuse treatment technologies may be another option for households wanting to treat irrigation water for domestic use.
5. See, for example, Tendlers (1997) discussion of the importance that centralized
functions had in development projects across several sectors in Cear, Brazil.
196
Notes
6. These costs may be particularly high in urban settings where water supply and
sanitation agencies are subject to technical standards that are often excessively stringent
or inappropriate. Many former colonies in Africa, for example, use construction standards
that were adopted without modication from Western Europe.
7. Some information was also supplied by task force cochair Albert Wright, based on
his personal knowledge of the program.
8. For instance, the technical standards for sewers in some African countries include
pipe specications intended to allow networks to withstand snow loadingsclearly an
artifact of the European climates in which the standards were developed.
Chapter 5
1. For example, most of the worlds poorest countries did not include target 10 among their
priority objectives in their Poverty Reduction Strategy Papers (PRSPs). See Mehta (2002).
2. Ring-fencing refers to the compulsory reservation of funds for use within a specic
limited sector or department, such as a specic agency, utility, or division of a company. It
implies, for instance, that income a utility gains from providing water supply would then
remain with that utility to cover operation and maintenance costs, to pay salaries, or to
fund expansion of services.
3. The term institutional constraints refers to obstacles developing countries face in
a wide range of areas required for effective development policy-making and implementation, such as human resources, managerial skills, monitoring and evaluation systems, work
processes, organizational cultures and norms, and legal frameworks.
4. We use the term capacity building as dened in Agenda 21 (chapter 37): capacity building encompasses the countrys human, scientic, technological, organizational,
institutional and resource capabilities. A fundamental goal of capacity building is to
enhance the ability to evaluate and address the crucial questions related to policy choices
and modes of implementation among development options, based on an understanding
of environment potentials and limits and of needs perceived by the people of the country
concerned (UNCED 1992).
5. The Orangi Pilot Project in Pakistan is a well-known example of this type of bottom
up capacity building that led to a locally planned and implemented sanitation project.
6. In nominal terms, ofcial development assistance for water and sanitation has
declined since 1995, uctuating between $18 billion in 1996 and $13.5 billion in 1999.
These commitments were about $16 billion in 2002.
7. Calculated based on Silva and others (1998) as quoted in Annamraju and others
(2001).
Chapter 6
1. For example, improved sanitation services are far more effective than improved
water supply in reducing the incidence of such diarrheal diseases as cholera, thereby reducing public health costs, improving the productivity of workers, and underpinning higher
academic attainment for children. While benecial to individuals and households, these
effects also have substantial macroeconomic impacts on the economies of their countries as
well. (See, for example, Evans and others 2004.)
2. Of course, along with consumer demand for sanitation, it is important to recognize
several other factors that can inuence the likelihood that improved facilities will be constructed. These include access to water supply; security of land tenure; awareness of various technological options; availability of materials and personnel (for example, masons)
Notes
197
needed for construction; and such technical considerations as availability of sufcient

space to construct a latrine or bathroom, or proximity to a feeder sewer.
3. While many countries have already achieved this type of decentralization, others
have not; many centralized water and sanitation agencies still take full responsibility for all
aspects of sanitation service delivery.
4. There is a pressing need for more analysis of the most effective ways of utilizing
public funds to leverage increased access. The success of approaches such as that adopted
by ZimAHEAD in Zimbabwe, and the total sanitation campaign in Bangladesh, certainly
point to the need to focus on and support local decisionmaking. A recent evaluation of
hygiene promotion programs also suggested that their impacts are robust and long lasting
(Bolt 2004; Cairncross and Schordt 2004). Further work is needed, however, to evaluate
the conditions under which different approaches work best.
5. The role of public funding in urban sanitation is crucial. In congested urban areas,
shared infrastructure or systems of waste disposal are essential if household actions are to
result in a cleaner and healthier living environment.
6. It is important to note, however, that progress toward the environmental sustainability goal is still constrained by the lack of sanitation technologies that address waste
management adequately. Technical advances in such areas as effective, affordable, and
simple-to-operate sewage treatment plants that can be located close to residential areas;
drainage and solid waste disposal; and urban wastewater treatment and management in
large urban agglomerations should therefore be promoted and accelerated.
7. Whereas the community-led total sanitation approach explicitly prohibits subsidies for the construction of sanitary facilities, there may be cases in which cross-subsidies among households or direct subsidies to poor households are justied. Given the
wide range of socioeconomic characteristics, technical challenges, and costs of providing
improved service found across unserved communities, blanket principles regarding subsidies are inappropriate.
8. Various tools exist for promoting dialogue on sanitation. The construction of simple latrine acquisition curves, for example, can force professionals into a discussion with
households about what has changed over time, and the reasons some households have made
investment and behavior decisions about sanitation and hygiene while others have not.
Chapter 8
1. The full needs assessment methodology can be found at www.unmillenniumproject.
org/html/mpmethodology1.shtm. Special thanks to Guido Schmidt-Traub, who conducted
the analysis outlined in this section and wrote the text that follows.
2. The water and sanitation needs assessment does not include the following interventions: soakaway pits for treating and disposing of sullage; large-scale infrastructure for
water storage and transport; infrastructure for ood management and control; upgrading
of existing water and sanitation infrastructure; advanced wastewater treatment for industrial efuents and other chemicals; or integrated water resources management (IWRM),
including hydrological monitoring systems.
3. Macro International website www.measuredhs.com.
4. Albert Wright, a coordinator of the task force, has kindly provided us with these
principles. They should, however, not be misinterpreted as rules. Instead, countries must
develop their own coverage targets based on local needs and preference.
5. Estimating human resources, administrative capacity, and related costs pertaining to the maintenance of water and sanitation is extremely difcult. For example, staff
requirements for water and sanitation systems can vary between 2 and 10 employees per
198
Notes
10,000 users, depending on the complexity of the system, its efciency, and the extent to
which automation or labor-intensive approaches are used (Muller 2003).
6. Macro International website www.measuredhs.com.
7. The reason is that, although septic tanks are a very good means of disposing of
human excreta if properly maintained, experience has shown that systematic maintenance
and regular emptying are difcult to ensure.
8. www.sulabhinternational.org.
9. UNAIDS is an innovative joint venture of the United Nations family that brings
together the efforts and resources of 10 UN system organizations. It has been successful in
putting AIDS on the global agenda, which has generated additional funds for the sector from
the Bill and Melinda Gates Foundation to create the Global Fund. See www.unaids.org.
10. The UN Millennium Project is working with a number of governments to revise
the preliminary estimates.
11. www.unmillenniumproject.org
Chapter 9
1. The number of people below the poverty line has been calculated by multiplying
the national poverty headcount ratio by the population. National poverty headcount ratios
are taken from the World Development Indicator database (World Bank 2004). Countries
for which no poverty or water and sanitation data are available are not included in the
calculations, which is why the totals are less than the total number of unserved people, for
both water and sanitation. We are grateful to Michael Krause and Alice Wiemers of the
Millennium Project Secretariat, who carried out this analysis.
2. The Ethiopian national poverty line is substantially below the $1 a day standard
used by the World Bank.
3. National poverty lines are typically dened as the income equivalent required to
meet minimum caloric food requirements as well as basic essential expenditures. In most
countries, households living below the national poverty line have insufcient resources to
provide sufcient food for all household members.
4. For example, aid modalities are discussed in some detail in UN Millennium Project
(2004b).
Chapter 10
1. Table 10.1 and the following four sections (on poverty and hunger, environmental
sustainability, health, and gender equality) draw extensively on UNDP 2004 and on material prepared by John Soussan of the Stockholm Environment Institute at the request of the
task force coordinators. Special thanks to task force member Ingvar Andersson of UNDP
for allowing us to incorporate sections of the UNDP report verbatim.
2. Schistosomiasis, also known as bilharzia, is a disease caused by water-borne atworms or blood ukes that spend part of their development in human intestines or in their
urinary tracts; the second part of their development takes place in small water snails (that
act as intermediate hosts of the atworms) when they are discharged into surface waters
through feces or urine. The disease is endemic in 74 developing countries, affecting people
in agricultural and periurban areas. It is a disease of great public health and socioeconomic
signicance. Those with the urinary types of the disease discharge blood in their urine and
sometimes develop bladder cancer.
3. The material in this section is drawn from Scherr 2004.
4. Direct irrigation refers to wastewater streams being applied directly, undiluted, and
often untreated, to agricultural land. Indirect irrigation with wastewater takes place when
Notes
199
wastewater is discharged in streams or irrigation canals, mixed with freshwater and used
for irrigation diluted.
5. Virtual water is the amount of water that is embedded in food or other products
needed for its production. Trade in virtual water allows water-scarce countries to import
high water-consuming products, while exporting low water-consuming products, and in
this way make water available for other purposes.
Chapter 11
1. Global Water Partnership www.gwpforum.org.
2. These are the areas that have been dubbed economically water scarce by the
International Water Management Institute.
3. These events will in turn impact hydropower, dilution capacity, transport, ood
control, and agricultural production and thus threaten gains made toward the poverty,
hunger, health, and environmental sustainability Goals.
4. An IWMI study projects that about a quarter of all the population in 2025 live in
countries that do not have sufcient water resources to meet reasonable needs without relying on high food imports (Seckler and others 1998).
Chapter 12
1. For example GRID; GEMS-Water; the Global International Waters Assessment
(GIWA) of the UN Environment Programme; the Global Runoff Data Center (GRDC) of
the World Meteorological Organization (WMO); AQUASTAT of the Food and Agriculture Organization; the International Groundwater Resources Assessment Centre (IGRAC)
of WMO and UNESCO, the water supply and sanitation databases of the World Health
Organization and UNICEF; and the databases of the World Bank Group.
Appendix 1
1. Special thanks to Robert Chambers and Kamal Kar for preparing this case
study.
2. This case study is based on WSSCC (2000). Some information was also supplied
by task force co-chair, Albert Wright, based on his personal knowledge of the program.
3. This case study is based on Water and Sanitation Program (2002). Additional
information provided by Mi Hua, task force member and UN Millennium Project water
and sanitation specialist.
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Halving hunger: it can be done
Task Force on Education and Gender Equality
Toward universal primary education: investments, incentives, and institutions
Taking action: achieving gender equality and empowering women
Task Force on Child Health and Maternal Health
Whos got the power? Transforming health systems for women and children
Task Force on HIV/AIDS, Malaria, TB, and Access to Essential Medicines
Working Group on HIV/AIDS
Combating AIDS in the developing world
Working Group on Malaria
Coming to grips with malaria in the new millennium
Working Group on TB
Investing in strategies to reverse the global incidence of TB
Working Group on Access to Essential Medicines
Prescription for healthy development: increasing access to medicines
The UN Millennium Project is an independent advisory body commissioned by the UN
Secretary-General to propose the best strategies for meeting the Millennium Development Goals
(MDGs). The MDGs are the worlds targets for dramatically reducing extreme poverty in its
many dimensions by 2015income poverty, hunger, disease, exclusion, lack of infrastructure and
shelterwhile promoting gender equality, education, health, and environmental sustainability.
Task Force on Environmental Sustainability

Environment and human well-being: a practical strategy
The UN Millennium Project is directed by Professor Jeffrey D. Sachs, Special Advisor to the
Secretary-General on the Millennium Development Goals. The bulk of its analytical work has
been carried out by 10 thematic task forces comprising more than 250 experts from around
the world, including scientists, development practitioners, parliamentarians, policymakers,
and representatives from civil society, UN agencies, the World Bank, the International
Monetary Fund, and the private sector. The UN Millennium Project reports directly to UN
Secretary-General Ko Annan and United Nations Development Programme Administrator
Mark Malloch Brown, in his capacity as Chair of the UN Development Group.
Task Force on Improving the Lives of Slum Dwellers

A home in the city
Task Force on Water and Sanitation

Health, dignity, and development: what will it take?
Task Force on Trade

Trade for development
Task Force on Science, Technology, and Innovation
Innovation: applying knowledge in development

Halving hunger: it can be done
Toward universal primary education: investments, incentives, and institutions
Taking action: achieving gender equality and empowering women
Task Force on Child Health and Maternal Health
Whos got the power? Transforming health systems for women and children
Working Group on HIV/AIDS
Combating AIDS in the developing world
Working Group on Malaria
Coming to grips with malaria in the new millennium
Working Group on TB
Investing in strategies to reverse the global incidence of TB
Working Group on Access to Essential Medicines
Prescription for healthy development: increasing access to medicines
The UN Millennium Project is an independent advisory body commissioned by the UN
Secretary-General to propose the best strategies for meeting the Millennium Development Goals
(MDGs). The MDGs are the worlds targets for dramatically reducing extreme poverty in its
many dimensions by 2015income poverty, hunger, disease, exclusion, lack of infrastructure and
shelterwhile promoting gender equality, education, health, and environmental sustainability.
Task Force on Environmental Sustainability

Environment and human well-being: a practical strategy
The UN Millennium Project is directed by Professor Jeffrey D. Sachs, Special Advisor to the
Secretary-General on the Millennium Development Goals. The bulk of its analytical work has
been carried out by 10 thematic task forces comprising more than 250 experts from around
the world, including scientists, development practitioners, parliamentarians, policymakers,
and representatives from civil society, UN agencies, the World Bank, the International
Monetary Fund, and the private sector. The UN Millennium Project reports directly to UN
Secretary-General Ko Annan and United Nations Development Programme Administrator
Mark Malloch Brown, in his capacity as Chair of the UN Development Group.
Task Force on Improving the Lives of Slum Dwellers

A home in the city
Task Force on Water and Sanitation

Health, dignity, and development: what will it take?
Task Force on Trade

Trade for development
Task Force on Science, Technology, and Innovation
Innovation: applying knowledge in development

Health, Dignity, and Development: What Will It Take?

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Health, Dignity, and Development: What Will It Take?

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First published by Earthscan in the UK and USA in 2005

The world has an unprecedented opportunity to improve the lives of billions

Health, Dignity, and Development has been prepared by a group of leading

The Millennium Development target for domstic

Chapter 2 Why focus on water supply and sanitation?

Chapter 3 Target 10 and the global monitoring system

Chapter 4 Where are the needs greatest?

Identifying greatest needs globally

Chapter 6 The special challenge of meeting the sanitation target

Chapter 9 Grappling with nancing for the poorest

Water resources for all the Millennium

Why does water resources development

Chapter 12 Monitoring and support systems

Achieving the Millennium Development Goals

Chapter 13 How to make the Goals a reality

Insights from case studies

Millennium Development target 10

Overcoming constraints and increasing access: the South African

Millennium Development Goals for water and sanitation reach the

Regional groupings for the Joint Monitoring Programme

Contribution of access to domestic water supply and sanitation to the

Task force members

Task force coordinators

Roberto Lenton, The Earth Institute at Columbia University

Ingvar Andersson, Senior Freshwater Advisor, United Nations Development

Task force members

Sir Richard Jolly, Fellow, Institute for Development Studies, University of

Kristen Lewis, Senior Policy Advisor and Task Force Manager

Barbara Evans, Independent consultant, Maccleseld, U.K.

In the past 25 years, a number of commissions, expert groups, and high-level

The UN Millennium Project Task Force on Water and Sanitation, together

This nal report is the culmination of three years of analysis, consultation

Millennium Development Goals

Millennium Development Goals

There is a deliberate recognition that basic sanitation in particular

mitted through water or human excrement are the second-leading cause of

International conferences and agreements on water and sanitation

Halve by 2015 the proportion of people without sustainable access to

Notably, the Plan of Implementation took a broad view of the actions

Although there is no global, comprehensive, intergovernmental structure for

Sanitation Collaborative Council (WSSCC) and its WASH (Water Sanitation

participation is critical to their success. Many institutions of local governance

a review of the current institutional and monitoring apparatus at the

The Millennium Development

Why focus on water supply

Expanding access to water and sanitation is a moral and ethical imperative

because they mobilize the enthusiasm and engagement of their communities,

Why focus on water supply and sanitation?

Contribution to the Millennium Development Goals

Expanding access to domestic water supply and sanitation services, as called

Contributions of domestic water supply and sanitation

Household livelihood security rests on the health of its members;

Community-based organizations for water supply and sanitation can

To have halted and begun

Why focus on water supply and sanitation?

adults) means that adults miss fewer days of work, be it as employees,

Why focus on water supply and sanitation?

inadequate sanitation and hygiene. Improved water supply reduces

Why focus on water supply and sanitation?

human as well as environmental health, fecal matter should be treated

sanitation facilities nonexistent). Having no safe, private sanitation facilities in

Why focus on water supply and sanitation?

relieving oneself and then risking exposure at nighta humiliating, stressful,

Why focus on water supply and sanitation?